Networked Care Pushed as a Fix for Texas Workers’ Comp Woes

May 7, 2004

The insurance industry told the Texas Senate Select Interim Committee on Workers’ Compensation that implementing an effective medical network system for the delivery of health care to injured workers will result in quality care, employees returning to work in an appropriate amount of time and better control of costs.

“Texas should adopt a medical network system in workers’ compensation that will provide quality care for injured employees,” said Joe Woods, assistant vice president and regional manager for the Property and Casualty Insurers Association of America (PCI). “Medical care would be delivered by appropriately trained providers, offer quicker and better medical outcomes and allow more employees to return to meaningful employment.”

The committee is holding a series of hearings on reforming Texas’ workers’ compensation system. PCI testified on behalf of the insurance industry regarding the potential impact of networks on the workers’ compensation health care delivery system.

For many years the state’s workers’ compensation system has been plagued by rising costs, poor medical outcomes and frustration by everyone involved in the system. Earlier this year, the Workers Compensation Research Institute (WCRI) reported that costs per claim in Texas increased at double-digit rates for the third consecutive year. The study said that the average total cost per workers’ compensation claim rose 10 percent between 2000 and 2001, following an 11 percent increase between 1999 and 2000 and a 13 percent increase between 1998 and 1999.

“We provided the committee with a solid starting point for developing a network system. In addition to addressing return to work issues, the network approach allows medical providers to practice medicine within a system that will fairly compensate them for their efforts and not overwhelm them with administrative burdens. By achieving meaningful reform, costs can be controlled, which will help employers better afford to offer workers compensation as an employee benefit in Texas,” Woods said.

Based on the network model presented by Woods, insurance carriers would be allowed to establish their own certified networks, or contract with other certified provider networks. When an employee is injured, the network would provide a list of available treating doctors. The treating doctor would make all referrals to a participating network provider.

Chiropractors would not be included as treating doctors and would be able to treat only upon referral from a treating doctor. Out of network care would not be reimbursed unless pre-authorized by the insurance carrier.

The vast majority of the disputes would be resolved at the network level based on contractual agreement between the network and providers. The appeals process would be based on the model being used by healthcare preferred provider organizations.

“Our basic premise is that by providing care through network doctors, trained in treating occupational injuries and who provide care consistent with nationally-recognized, evidence-based treatment standards, injured workers will receive the most appropriate medical treatment available and will return to appropriate work at the appropriate time,” Woods said.

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