PT and OT Preauthorization Mandatory Under Texas Workers’ Comp System Effective Dec. 1

December 22, 2005

House Bill 7 amended Texas Labor Code §413.014 by adding physical therapy and occupational therapy to the list of services requiring preauthorization. The Texas Department of Insurance, with bulletin B-0039-05, notified system participants that this provision would be effective upon adoption of rules.

Consistent with the statutory changes contained in HB 7, the Division of Workers’ Compensation adopted, on an emergency basis, changes to 28 TAC §134.600, related to Prospective and Concurrent Review of Health Care. The DWC recently issued a reminder that the emergency rule providing that physical and occupational therapy services provided on or after Dec. 1, 2005, require preauthorization was adopted with an effective date of Dec. 1.

The Division has received complaints regarding the preauthorization process for physical therapy and occupational therapy. Specifically, providers expressed concern that the preauthorization process resulted in delays to treatment for ongoing treatment plans for injured workers.

The language in the rule applies the preauthorization requirement for physical and occupational therapy services to dates of service on or after Dec. 1 and makes no distinction regarding the license of the person providing the services or the physical setting in which the services are rendered. In addition, the rule does not make any distinction between existing patients and new patients.

This new requirement was not intended to cause delays in ongoing treatment for existing patients, especially those who entered treatment prior to Dec. 1. Because a delay in treatment could cause clinical ramifications, providers and carriers are encouraged to work in a collaborative effort to coordinate preauthorization on an expedited basis for patients already in treatment.

Commissioner of Workers’ Compensation, Albert Betts, is encouraging carriers to expedite preauthorization by all available means, including streamlining information requested from providers and related paperwork with allowances for supplementation at a later date. Likewise, providers are encouraged to take proactive steps to anticipate the need for preauthorization in existing patients and to submit complete paperwork as soon as possible.

For example, a carrier could choose to approve preauthorization by telephone for additional visits to ensure existing patients do not have a break in treatment. Another example is that the provider could supply the specific information requested by the insurance carrier to help expedite the processing of the request for preauthorization (e.g., provide the specific modality/therapy codes even though they are not required under the rules).

Questions should be directed to Allen McDonald, director of Medical Review, Division of Workers Compensation, Texas Department of Insurance, at (512) 804-4803.

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