Fraud
- For fiscal year 2021, there were:
- 1,303 (down from 1,584) fraud reports received – this is the lowest number reported going back to 2014 when the data is available
- 68 cases opened for investigation (down from 134 in 2020)
- 2 cases referred for prosecution
- 16 convictions – the largest number of convictions since 2014
- On July 22, 2021, Clinton Battle, M.D. of Arlington pleaded guilty to defrauding the federal workers’ compensation program and Texas workers’ compensation insurance carriers by submitting fraudulent bills for physical therapy, office exams, and functional capacity evaluations for a period of five years starting in 2012. During that time Battle mischaracterized services so he could bill a higher rate, and, in several cases, he also billed for services that he claimed took longer than they actually did, were never conducted, or were conducted by unlicensed staff. He will pay $376,368 in restitution. A U.S. district judge sentenced Battle to 12 years in federal prison on March 24, 2022.
https://www.tdi.texas.gov/wc/ci/wcfraud.html#stats
2022 PBO Assessment Methodology
- The 2022 PBO Assessment will evaluate insurance carriers.
- Weighted measures will be the following:
- Timely payment of initial temporary income benefits by the insurance carrier – 50% weight.
- Timely processing of initial medical bills by the insurance carrier – 30% weight.
- Timely processing of request for reconsideration medical bills by the insurance carrier – 10% weight.
https://www.tdi.texas.gov/wc/pbo/icpbo.html
*Insurance Carrier Complaints received in 2021 – 1,855 (101 more than 2020)
Audits
Compliance and Investigations Audit Plan*
Audit for fiscal year ending Aug. 31, 2022 goals:
- timely and accurate benefit delivery;
- timely medical reimbursement; and
- timely and accurate reporting of electronic data to the DWC.
Insurance Carrier Audit Types with Review Periods- Accuracy of Lifetime Income/Death Benefit Payments and Claims Data – The sample data will be drawn from claims for injuries that occurred between Sept. 1, 2005 and April 30, 2021.
- The Timely Processing Medical Bills, Timely Reporting Medical Bill Data, and Accuracy of Medical Bill Data – The sample data will be drawn from billing lines submitted to DWC during the period of Sept. 1, 2021, through Nov. 30, 2021, or Dec. 1, 2021, through February 28, 2022, depending on the date of the audit initiation.
- Timely Paying Initial Temporary Income Benefits (TIB) Payment, Timely Reporting Initial Payment Data, and Accuracy of Initial Payment Data- The sample data will be drawn from claims where an insurance carrier issued an initial TIB payment during the period of either July 1, 2021, through Sept. 30, 2021, or Oct. 1, 2021, through Dec. 31, 2021, depending on the date of the audit initiation.
Number of audits done in FY 2021- 59
Medical Quality Review (MQR) Audit Plan Review Categories**
- The 2022 Medical Quality Review Annual Audit Plan, which sets the priorities for the Medical Quality Review audits during the upcoming year includes the following review categories:
- Evaluate the reasonableness of a doctor’s decision and recordkeeping regarding return-to-work.
- Evaluate the appropriateness of a health care provider’s decision-making and recordkeeping that supports the use and effectiveness of spinal cord stimulators.
Shoulder Surgery Plan Based Audit***
The purpose of the audit is to:
- promote the delivery of quality health care in a cost-effective manner, including protecting the safety of injured employees; and,
- ensure that health care providers adhere to the ODG and medically accepted standards of care for performing acromioplasty or distal clavicle resection procedures conducted as part of a shoulder rotator cuff repair, including the appropriate recordkeeping of these procedures.
Scope and Methodology:
- Includes health care providers who performed acromioplasty or distal clavicle resection procedures conducted as part of a shoulder rotator cuff repair for injured employees:
- Where the shoulder rotator cuff repair was billed with Current Procedural Terminology (CPT) codes 23410, 23412, or 29827;
- Where the shoulder rotator cuff repair was no earlier than 90 days from date of injury;
- Where the shoulder rotator cuff repair was the first rotator cuff repair; and
- Where the shoulder rotator cuff repair was also billed for an acromioplasty or distal clavicle resection procedure with CPT codes 29824, 29826, 23420, or 23120.
- Procedures for determining the reasonableness of a doctor’s decision and recordkeeping regarding return to work are set forth in Section II of the Medical Quality Review Process, specifically, the adopted return to work guidelines.
Selection Criteria:
- Health care providers will be identified through the medical bill and payment data.
- Cases will be identified through medical bill and payment data submitted to DWC with dates of service on or after July 1, 2019, through March 31, 2020, which contain CPT codes 23410, 23412, or 29827 as the primary procedure and CPT codes 29824, 29826, 23420, or 23120 as the secondary procedure.
DWC will select the top 10 health care providers who performed the most acromioplasty or distal clavicle resection procedures as part of a first-time rotator cuff repair procedure.
*According to DWC Compliance and Audit Plan
**According to MQR CY 2022 Annual Audit Plan
***According to Shoulder Surgery Plan-Based Audit