Big Changes this Fall in Texas Insurance

 

The Texas Department of Insurance announced four new initiatives, which we have summarized. The details of all can be found here:

 

1. Case management certification.
2. Establishment of procedures for insurance carriers to recoup overpayment.
3. Paper and electronic billing requirements for workers compensation.
4. Pharmacy closed formulary adoption.

 

1. Case Manager Certification

The first new rule establishes certification requirements for case managers working with insurance carriers on non-network workers compensation claims. Beginning Sept. 1, all managers must be certified in one of six ways. Other details as follows:

 

 

New managers must work under supervision of a certified manager an have 24 months to accrue necessary experience to sit certification exams.

Claims adjusters may no be used as case managers.

Insurance carriers must verify, document, and submit proof of certification.

 

 

2. Over and Underpayment Regulations

The second announcement regards the establishment of how insurance carriers get overpayment or how they should make an underpayment. Details of this new bill will be discussed in a series of meetings beginning Sept. 1 and also available via live audio stream. More information can be found on the Texas Department of Insurance website, here.

 

 

3. Paper and Electronic Billing Requirements

The third announcement regards the way billing is performed – regulations began August 1. Among the changes are:

1. All health care workers are subject to the rules.
2. Bills must be submitted electronically unless you are exempt.
3. If your office treated fewer than 32 injured workers or have fewer than 10 employees, you can file that electronic billing will cause undue financial hardship.
4. A workers compensation claim number and National Provider Identifier (NPI) must be on all bills.
5. State license numbers are required on all paper professional, institutional, and dental medical bills. They are not required on pharmacy bills or electronic bills after Jan. 1.

 

 

6. Pharmacy Closed Formulary

Finally, the last announcement regards the Texas workers compensation system adopting a pharmacy closed formulary in order to bring more drug prescribing consistency certified workers compensation health-care network and non-network claims. The outpatient open formulary (all FDA-approved prescription and non-prescription drugs) is still in effect until Sept. 1. Details on this transition, legacy claims and non-network requirements can be found here.

 

This information was provided by attorney Stuart Colburn, a Shareholder at Downs Stanford in Austin, Texas. Colburn has extensive experience in all phases of dispute resolution before the Texas Department of Insurance, Division of Workers Compensation and in district courts across the state. Stuart represents clients regarding workers compensation, non-subscription, subrogation, and bad faith litigation. He is the founder and the first chairman of the State Bar of Texas (SBOT) Workers Compensation Section; course coordinator for the SBOT the Advanced Workers Compensation Seminar; and course coordinator for the Texas Workers Compensation Forum. He can be reached at: scolburn@downsstanford.com

For complete contents of all state laws and legal research, contact: www.workcompresearch.com or rwilson@workerscompensation.com

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

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