Complaints
Insurance carrier complaints received in 2022 totaled 2,174 (+319 from 2021). 1,422 were closed.
- The highest number of complaints fell into the Communications category* (665), followed by Medical Benefit Delivery (635) and Indemnity Benefit Delivery (631).
*According to the DWC, communications is a large category and includes the failure of an insurance carrier to timely respond to a claimant’s inquire or notify a beneficiary of potential entitlement to death benefits. Communication complaints also involved complaints that are not related to workers’ compensation, such as matters concerning social security benefits and matters that are more appropriately handled by the Texas Medical Board, the Texas State Bar or the Texas Workforce Commission.
Fraud
For fiscal year 2022, there were:
- 1,323 fraud reports received–an overall decrease after a record spike in 2019
- 68 cases opened for investigation
- Two cases referred for prosecution
- Seven convictions
Historical Look at Workers’ Compensation Fraud Cases (by fiscal year)
2022 Fraud Cases Resolved
On March 24, 2022, a U.S. district judge sentenced Clinton Battle, M.D. of Arlington to 12 years in federal prison based on a conviction and guilty plea from July 2021. Battle admitted to submitting fraudulent bills for physical therapy, office exams, and functional capacity evaluations for five years starting in 2012. Battle was sentenced to 144 months, with 60 months directly related to submitting fraudulent workers’ compensation medical bills. He will also have to pay $376,368 in restitution and be under supervised release for three years after imprisonment.
Performance Based Oversight (PBO) Assessments
The 2022 PBO Assessment evaluated 136 insurance carriers.
- Weighted measures were:
- Timely payment of initial temporary income benefits by the insurance carrier – 50%.
- Timely processing of initial medical bills by the insurance carrier – 30%.
- Timely processing of a request for reconsideration of medical bills by the insurance carrier – 10%.
- Timely submission of initial payment data via Electronic Data Interchange (EDI) – 5%.
- Timely submission of medical bill processing data via EDI – 5%.
Results
High Tier Performers
Average Tier Performers
Poor Tier Performers
In 2023, DWC will evaluate healthcare providers in the System with the following measures:
- Documentation of off-work status supporting how the injured employee’s medical condition prevents them from returning to any work as reported on the DWC Form-073, Work Status Report
- Completeness of the DWC Form-073
- Designated doctors’ timeliness of filing the DWC Form-069, Report of Medical Evaluation with DWC
