Health care networks coming soon to Texas workers’ comp system
In certain situations, employees may seek care outside the network. An employee who has a pre-existing relationship with an HMO doctor may receive treatment for a workers’ compensation injury from that provider.
Health care costs in the Texas workers’ compensation system are among the highest in the nation. Furthermore, studies suggest that one out of every four injured employees does not return to work. In an effort to improve the system, the Texas Legislature in Spring 2005 passed House Bill 7, which is currently being implemented by the Texas Department of Insurance Division of Workers’ Compensation.
One high-profile provision of HB 7 allows insurance carriers to establish or contract with health care networks. Networks should help control health care costs in the system and reduce premiums.
All networks that wish to participate in the workers’ compensation system must apply for certification by TDI. Under the law, an insurance carrier may not offer a policy with network coverage until the network has been certified by TDI, which began accepting applications for certification in January 2006. The agency has 60 days to approve or deny each completed application.
Why choose network coverage?
Employers who take advantage of the network option will enjoy benefits beyond a premium discount. HB7 provides for a new model of health care, one in which the primary goal is to return injured employees to work as soon as medically reasonable.
This renewed emphasis on return-to-work is good for employers and employees. Studies show that injured employees who go back to work actually recover faster. Early return-to-work also minimizes the effects of paying overtime, hiring extra help, and other costs associated with workplace accidents.
The new law requires health care providers to be versed in occupational medicine. Health care providers must rely on evidence-based treatment and return-to-work guidelines adopted by networks in delivering care. Additionally, networks must have quality improvement programs that include case management to identify injured workers who need extra attention.
To help ensure that the new system achieves its goals, HB 7 requires TDI to produce “consumer report cards” that measure such things as the networks’ return-to-work outcomes, access to care, health care costs and utilization. It also requires the Department of Assistive and Rehabilitative Services to help injured workers who need to be retrained before they can re-enter the workforce.
For the new system to be effective employers play an important role. If injured workers cannot perform all of their original job duties, their treating doctor may release them to return to work under modified duty. Employers should work with providers and insurers to identify modified-duty assignments and accommodate injured employees’ work restrictions.
Employers’ responsibilities
Network participation comes with responsibilities. If employers do not fulfill their responsibilities, the network provisions will not take effect. When employers select the network option, they must give all current employees a notice of network requirements. They must also give the notice to new employees and to all employees who are injured on the job.
The notice must be in English, Spanish and any other language common to employees. It must include a list of network providers, a notice that the employee must see a treating doctor in the network, an explanation of the complaint process, and other information the employee needs to receive care within the network.
Employers must have each employee sign a form acknowledging receipt of the notice, and employers must establish a standardized process for delivering the notice. If an employee refuses to sign the acknowledgment, he or she will still be required to comply with the terms of the network if the employer maintains a record of delivery.
Employees’ responsibilities
Employees have network responsibilities, too. If they do not fulfill their responsibilities, they may have to pay for their own health care.
Injured workers who have received the notice and who live within the network’s service area must receive care from a network treating doctor. Employees who are not satisfied with their initial choice of treating doctor may change the treating doctor within the network one time. After that, the network must approve treating doctor changes.
In certain situations, employees may seek care outside the network. An employee who has a pre-existing relationship with an HMO doctor may receive treatment for a workers’ compensation injury from that provider. The provider must agree to the terms and provisions of the network in order for this exception to take effect. An employee may also go outside of the network for emergency care or to receive treatment from a specialist referred by the network treating doctor.
Jeremiah Bentley is public affairs analyst with Texas Mutual Insurance Company. Texas Mutual is preparing for the 2006 launch of its workers’ compensation health care network option and is in the final stages of selecting its network partner. Employers who participate in the network will earn a premium discount, regardless of the renewal date on their policy. The company will work with agents to offer the network option to employers as soon as possible after its network partner receives TDI certification. Employers can contact their agent or visit www.texasmutual.com/employers/networkph.shtm for more information.