Peer Review Data Calls To Be A Reality in Texas

Saturday, September 9, 2006 | 0

On May 24, Workers' Compensation Commissioner Albert Betts announced that the Division of Workers' Compensation (DWC) intends to collect peer review information from insurers through the use of data calls. The announcement was made during the Texas Department of Insurance Working Group meeting held in Austin, Texas.

Betts and Allen McDonald, the DWC's deputy commissioner for workplace and medical services, provided work group members and other stakeholders with an overview of the peer review data call process.

The data calls will focus on doctors selected by an insurer to review the medical care provided to an injured employee by another health care provider. The peer review data calls will be made by the DWC on a quarterly basis.

"In collecting the data, the division would be in a position to more accurately report on the system use of peer review doctors," said Deputy Commissioner Allen McDonald. "Information regarding the purpose for the reviews and eventual outcome will be helpful to show potential system impact."

Deputy Commissioner McDonald also noted that the collection of peer review data will be helpful to assist the DWC with identifying trends or areas that require investigation by the state's workers' compensation regulatory agency.

Commissioner Betts to Appoint Work Group To Examine Related Data Issues

Betts received a significant amount of feed back from the members of TDI's Workers' Compensation Working Group. The working group members raised several issues about what data should be included in the data call.

The feedback from the working group members prompted Betts to announce that he will appoint a small group to look at issues related to the proposed peer review data calls.

Outstanding Issues Discussed At Working Group Meeting

The following issues were discussed during the May 24th working group meeting:

* How frequently should a data call be issued?

DWC staff proposed the use of quarterly calls for peer review data. The DWC's staff believes the use of quarterly data calls will ensure that analysis and further action, if required, can be performed in a reasonable period of time to improve performance by peer review doctors and insurers.

* Which insurers should be required to submit data?

DWC staff proposed to limit the initial data calls to only the largest insurers and certain governmental entities. The DWC's staff believes that the larger insurers, combined with the larger governmental entities, should provide sufficient peer review data to determine how peer reviews are used in the Texas workers' compensation system. Deputy Commissioner McDonald noted that at some future point in time, or in the event of multiple complaints regarding a specific insurer, data calls can be issued to those insurers that are not included in the routine reporting schedule. In addition, DWC staff believes that at least three months of data would be required for appropriate analysis of system trends related to the use of peer review doctors by insurers.

* What are the system and/or fiscal impact on insurers?

Deputy Commissioner McDonald said that while it is possible that some insurers may already collect data regarding the use of peer reviews, it is likely that the new data collection requirement will require the enhancement of existing claims, utilization, or information systems. McDonald said that the DWC wants to take into consideration any and all costs that may be incurred by insurers who will be required to collect and report specific peer review data.

Initial Data Call May Come As Early As September or October 2006; Insurance Industry Trade Group Expresses Concerns

McDonald announced that, subject to the date the new peer review rules are adopted, the DWC anticipates that the initial data call will be issued in September or October of 2006.

Subsequent to the meeting, the Insurance Council of Texas contacted the DWC and asked that insurers be provided with prospective notice of required data elements and time to collect data prior to the initial data call.

Steve Nichols, insurance council's manager of workers' compensation services, noted that the now defunct Texas Workers' Compensation Commission (TWCC) passed a rule that included provisions for the collection of preauthorization and concurrent review data and then proceeded to require insurers to submit specific data for which insurers were never told to collect. Nichols said the first call for preauthorization and concurrent review data made by the TWCC was done prior to insurers being notified of the specific data that must be submitted.

"The first attempt by the TWCC to request data resulted in insurers being required to expend a significant amount of resources in their attempt to report the data requested by the state's workers' compensation regulatory agency," said Nichols. "Many insurers were unable to comply with the initial request for data by the date TWCC specified for filing of the data - the entire process would have been more successful had TWCC provided insurers with advance notice of the data that would be requested and only requested data insurers had actually collected in anticipation of the initial call for data."

The council asked that the DWC take TWCC's past experience in consideration when determining the date for the initial call for data.

"The Insurance Council of Texas has been assured by Deputy Commissioner McDonald that the DWC will make sure that insurers have timely notice of the data that must be reported and give insurers time to collect the required data prior to making the initial data call," said Nichols. "ICT is pleased to hear that the DWC is on top of this issue and will make sure insurers are aware of what data must be collected and have an opportunity to collect data prior to the first call for data."

Article republished with the permission of the Insurance Council of Texas. www.insurancecouncil.org

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