texas workers` compensation update

Transcription

TEXAS WORKERS’
COMPENSATION UPDATE
Developments Impacting the Texas Workers’ Compensation System
August 28, 2013
The Texas Legislature Has Come and Gone: Few Workers’ Comp Bills Passed
By Albert Betts, General Counsel, Insurance Council of Texas and Partner at Thompson Coe
The 83rd Texas Legislature convened on Tuesday, January 8,
2013 and began its 140-day legislative session. The legislative session ended on Monday, May 27, 2013. The 83rd
Texas Legislature included many new members and second
term members who were anticipated to have a steep learning
curve as they became ―educated‖ about how the Texas
Legislature works and the various issues facing the
Legislature in 2013.
The 150-seat Texas House of Representatives (House)
convened with 43 new (freshman) legislators and 24
sophomores (second term members). The 2010 and 2012
election turn over in House members reduced the experience level in nearly half the House.
The Texas Senate also experienced significant turnover with 6 new members in the 31 member Senate.
Despite these changes, the Senate‘s political composition remained 12 Democrats and 19 Republicans. The
Senate‘s newest member took the Senate District 6 seat after winning a run-off election held on March 2,
2013. Sylvia Garcia, a Democrat and former Harris County commissioner, defeated State Representative
(and fellow Democrat) Carol Alvarado in the run-off election to fill the seat held by the late Senator Mario
Gallegos who was re-elected in November 2012 after having passed away prior to election day. Garcia was
sworn into the Senate on March 11, 2013.
2013 Legislation and Legislative Issues – 6,061 Bills Filed
There was not much anticipated for workers‘ compensation related legislation this session given that the
Division of Workers‘ Compensation sunset review occurred in 2011 and there were not any pressing issues
for the workers‘ compensation system heading into the session.
The 83rd Texas Legislature focused on the state budget, education funding, and state infrastructure issues.
The legislature faced tough questions on whether to expand funding for Medicaid, public policy issues
regarding the state‘s long term water supply, transportation, stopping the diversion of state dedicated funds,
eliminating waste in the state budget, lowering taxes, and the demand for more social services.
The Texas Legislature passed Senate Bill 7 and prohibited the expansion of Medicare as provided for by
the Affordable Care Act, also referred to ―Obama Care‖. Gov. Perry has previously informed the Obama
Administration that Texas will not expand Medicare.
The legislature also addressed the continuation of certain major state agencies as part of the Sunset Review
process. These agencies include the Department of Criminal Justice, Lottery Commission, Railroad
Commission, and Education Agency. All of these agencies were continued by the Texas Legislature.
Continued on Page 8.
Copyrighted Publication of the Insurance Council of Texas
The Insurance Council of Texas (ICT) has been following several significant developments that
impact the Texas workers’ compensation system.
The following developments are reported on in this edition of the Texas Workers’ Compensation
Update newsletter:
Articles
Page Number
The Texas Legislature Has Come and Gone: Few Workers‘ Comp Bills Passed
1
Insurance Industry‘s Privileged Communications Legislation Falls Short and is Not Passed
10
Legislation to Covert Texas Mutual Into an Independent Mutual Insurance Company Not
Passed
12
Ron Cobb Honored with Raymond Mauk Award
16
Gov. Perry Announces He Will Not Seek an Additional Term in Office
17
Gov. Perry Vetoes Bill That Would Have Allowed Physician Dispensing of Cosmetic Drugs
18
Gov. Perry Signs Several Workers‘ Compensation Related Legislation Into Law
19
NCCI Names Katherine Antonello, FCAS, MAAA, as Chief Actuary
19
Texas Legislature Passes Legislation Authorizing Informal and Voluntary Networks for
Durable Medical Equipment and Home Health Care Services
22
Work Loss Data Institute Releases Opioid Outreach Flyer
23
Well Respected Former DWC Work Place Safety Expert Passes Away
24
Commissioner of Workers‘ Compensation Appoints New Medical Advisor
25
Featured Articles
Insurance Industry‘s Privileged Communications Legislation Falls Short and is Not Passed
Page 10
Legislation to Covert Texas Mutual Into an Independent Mutual Insurance Company Not
Passed
Page 12
Page 16
Medicare Secondary Payer Statute Does Not Preempt Texas‘ Preauthorization Law
Page 35
TDI Says All Health Care Providers Who Conduct Utilization Must Be Licensed in Texas
Page 48
Updated Report on Impact of Texas Pharmacy Closed Formulary Rules Released byTDI
Page 51
DWC Announces New Deputy Commissioner of Hearings
Page 55
DWC Reminds System Participants of Pharmacy Informal and Voluntary Network
Registration and Reporting Requirements
Page 58
NCCI Outlook on Workers‘ Compensation Industry: ―Encouraging‖
Page 62
August is the Most Dangerous Month for Texas Workers According to Travelers
Page 71
Copyrighted Publication of the Insurance Council of Texas – August 28, 2013
Page 2
Articles
Page Number
Amended Rules Regarding Certification of MMI and Evaluation of Permanent Impairment
Adopted
25
Catastrophic Case Management: An Inide Look
26
Medication Safety: An Inside Look
32
Medicare Secondary Payer Statute Does Not Preempt Texas‘ Preauthorization Law
35
In Memorium – Randall M. McNeel, Jr.
36
Payers, Providers Optimistic About Speciality Networks Bill
37
Believers in Texas Opt-Out Model Fear Oklahoma-Type Mandate
39
DePaolo‘s Work Comp World Column: Texas Case Highlights Importance of Comp
42
New AMA Classification of Obesity: How It Affects Workers‘ Comp and Mandatory
Reporting
44
New Accident Preventation Rules Adopted by Commissioner of Workers‘ Compensation
48
TDI Issues Data Call for Closed Formulary Legacy Claims
50
Updated Report on Impact of the Texas Pharmacy Closed Formulary Released by TDI
51
DWC Sought Input on Development of Legacy Claims Pain Management Plan-Based Audit
53
55
DWC Seeks Input on Maximum Hourly Rate for Attorneys and Legal Assistants Handling
Workers‘ Compensation Cases
55
DWC Annouces New Test and Test Administration Vendor to Certify Maximum Medical
Improvement and Permanent Impairment
56
DWC Proposes Repealing Rules Considered To Be No Longer Needed
58
DWC Reminds System Participants of Pharmacy Informal and Voluntary Network Registration
and Reporting Requirements
58
Texas Business Indicted on Workers‘ Comp Fraud Charges
60
DWC Announces Dates and Locations for Workers‘ Compensation Education Conferences
60
Texas Companies Receive Safety Award at Texas Safety Summit
62
NCCI Outlook on Workers‘ Compensation Industry: ―Encouraging‖
62
Navigating ICT’s Newsletter Is Easy
Did you know that you can navigate ICT‘s workers‘ compensation newsletter by clicking on the page number
located in the articles table of contents?
Page 3
Articles
Page Number
Medical Services for Claims 20 or More Years Old Will Likely Account for More Than 10
Percent of the Cost of Medical Benefits for Workplace Injuries in 2013
64
American Insurance Association Backs Legislation to Extend Terrorism Risk Insurance Program
65
What Does the Future Hold for the Terrorism Risk Insurance Act
67
DWC Announces Approval of Eleven Request for Renewal Certificates of Authority to SelfInsure
70
Mineral Wells Man Sentenced for Workers‘ Comp Fraud
70
71
Workers‘ Compensation News Briefs
74
DWC Finalizes Health Care Providers Pain Management (Opiod) Plan-Based Audit
77
FDA Approves Abuse-Deterrent Labeling for Reformulated OxyContin
81
Significant Texas Case Law Update from WorkCompCentral
85
Workers‘ Compensation Events Calendar
91
Did you know that you can navigate ICT‘s workers‘ compensation newsletter by clicking on the page number
located in the articles table of contents?
Page 4
TEXAS WORKERS’ COMPENSATION UPDATE
A Copyrighted Publication of the Insurance Council of Texas
Rick Gentry, Executive Director
Steve Nichols, Manager, Workers‘ Compensation Services and Newsletter Editor
[email protected]
Cynthia Haywood, Assistant Newsletter Editor
[email protected]
The Texas Workers’ Compensation Update, published by ICT Services, Inc., is Texas‘ premier source
for news on developments in the Texas workers‘ compensation system. The newsletter includes articles
written by Insurance Council of Texas staff and contributing authors who have extensive experience
with the Texas workers‘ compensation system. The views expressed in articles that have been
contributed to the newsletter do not necessarily reflect the views, opinions, or position of the Insurance
Council of Texas or its member companies.
Subscription Price:
$150 per year for electronic
subscription
No Cost for ICT Members
and Associate Members
Comments and Inquiries:
Please send all comments or inquiries to Steve Nichols at the
following address, telephone number, or above referenced Email address:
ICT Services, Inc.
P.O. Box 15
Austin, Texas 78767-0015
Phone 512/ 444-9611 ● Fax 512/ 444-0734
Available as an electronic publication only.
Did you know that you can navigate ICT‘s workers‘ compensation newsletter by clicking
on the page number located in the articles table of contents at the beginning of the newsletter?
Page 5
ADVERTISEMENTS INDEX
Advertiser
Page Number
Thompson, Coe, Cousins and Irons, L.L.P.
14
ICT‘s 2013 Workers‘ Compensation Conference
15
Smith & Carr, P.C.
20
Thorton Law Firm
21
Stone Loughlin & Swanson, L.L.P.
31
Flahive, Ogden & Latson, Attorneys at Law, P.C.
49
Downs Stanford, P.C.
52
Progressive Medical
54
NCCI Holdings, Inc.
57
UniMed Direct
61
Pate Rehabilitation
66
Forté Texas Workers‘ Compensation Network Solution
69
Burns Anderson Jury & Brenner, L.L.P.
73
GENEX
75
Risk & Insurance
76
The National WWII Museum
78
JI Companies
79
JOPARI Solutions, Inc.
80
Texas Committee on Insurance Fraud
82
Professional Associates
83
Work Loss Data Institute ODG Treatment in Workers‘ Comp
84
Coventry Workers‘ Comp Services
86
Mitchell Workers' Compensation Solutions
87
Property and Casualty Insurers Association of America
88
Insurance Council of Texas Associate Membership
89
EK Health
90
Page 6
Continued from Page 1: The Regular Session of the 83rd Texas Legislature Has Come and Gone
2013 was no different than any other session as legislators filed and considered a significant number of bills
during each legislative session with only a small number of bills actually passed. In 2011, legislators filed and
considered over 6,003 bills. There were slightly more, 6,061 bills filed during the current session. This
included 40 bills related to workers‘ compensation. March 8, 2013 was the deadline for filing bills and joint
resolutions other than local bills, emergency appropriations, and bills that were declared an emergency by
Governor Rick Perry.
Once filed, bills were referred to the appropriate committees in the Texas House of Representatives and Texas
Senate. Many of the bills were heard in committee but some were never heard by a committee. For those bills
that were considered in committee, many did not make it out committee. The remaining few that made it out of
committee were either heard on the House or Senate floor, or simply died in calendars or was not heard on the
floor. The few surviving bills then were considered by the House or Senate, and a lucky few passed both
chambers. These bills have been forwarded to Governor Rick Perry‘s desk to either be signed into law or
vetoed. An overview of the legislative process can be found here.
Straus Re-Elected Speaker of the Texas House of Representatives
On the first day of the 2013 Legislative session Rep. Joe Straus (R-San Antonio) was re-elected to the position
of Speaker of the Texas House of Representatives.
House Committee Assignments Announced and Initial Activity on Legislation
On January 31, 2013, Speaker Straus announced the Texas House of Representatives (House) committees for
the 83nd Texas Legislature. Rep. Dennis Bonnen (R-Angleton) was named Speaker Pro Tempore. A number
of committee assignments are based on members‘ seniority. The House has 38 standing committees and three
select committees for the 83rd Legislature.
The Speaker appointed Rep. Rene Oliveira (D-Brownsville) as the Chairman of the Texas House of
Representatives‘ (House) Business & Industry (B&I) Committee. Workers‘ compensation legislation has
historically been referred to and considered by the B&I Committee which is responsible for oversight of the
Division of Workers‘ Compensation and Office of Injured Employee Counsel.
The majority of workers‘ compensation legislation was referred to the House B&I Committee. Some
workers‘ compensation legislation was referred to the House Insurance Committee which is chaired by Rep.
John T. Smithee (R-Amarillo).
Senate Committee Assignments Announced and Interim Study Reports Issued
On January 18, 2013, Lt. Governor David Dewhurst announced Texas Senate Committee assignments for the
83rd Legislature. Workers‘ compensation legislation has historically been referred to and considered by the
Senate State Affairs Committee. The committee is chaired by Sen. Robert Duncan (R-Lubbock) and co-chaired
by Sen. Robert ―Bob‖ Deuell (R-Greenville). A list of the members of the committee is available on the Texas
Senate‘s website.
On January 28, 2013, the State Affairs Committee released its Interim Report to the 83rd Texas Legislature.
The committee was charged with examining the Texas Workers Compensation system and making recommenddations for changes to meet the needs of Texas employers and employees. The committee did not make
any recommendations for the workers‘ compensation system. Selected findings from the Interim Report are
available here.
Page 7
Reappointment and Confirmation of Commissioner of Workers’ Compensation and
Injured Employee Public Counsel
On Feb. 26, 2013, Gov. Rick Perry announced that he had reappointed Rod Bordelon Jr. as Commissioner of
Workers' Compensation at the Texas Department of Insurance‘s Division of Workers‘ Compensation for a
term to expire Feb. 1, 2015. Bordelon has served as the Commissioner of Workers' Compensation since his
appointment to the position in September 2008. He is former public counsel for the Office of Public Insurance
Counsel. Bordelon‘s reappointment was confirmed by the Texas Senate on March 13, 2013.
On March 1, 2013, Gov. Rick Perry announced the reappointment of Norman Darwin to continue to serve as
the Injured Employee Public Counsel for a term to expire Feb. 1, 2015. Darwin is an attorney and the current
public counsel for the Office of Injured Employee Counsel, a position he has held since his appointment in
December 2005. Darwin‘s reappointment was confirmed by the Texas Senate on March 6, 2013.
Insurance Commissioner Kitzman Not Reappointed Nor Confirmed; Texas Gets a New Insurance
Commissioner
Commissioner Eleanor Kitzman was neither reappointed by Gov. Perry nor confirmed by the Senate to serve a
two year term as Texas‘ Insurance Commissioner. Pursuant to the provisions of Art. IV, Section 12 of the
Texas Constitution, Kitzman could not continue to serve as insurance commissioner and had to step down.
(News coverage of this development can be found on the Texas Tribune and The Dallas Morning News
websites.)
On May 27, 2013, Gov. Perry appointed Julia Rathgeber of Austin as
the new Commissioner of Insurance for a term to expire Feb. 1, 2015.
At the time of her appointment, Rathgeber was the Deputy Chief of
Staff in the Office of Lt. Gov. David Dewhurst. Rathgeber‘s appointment was confirmed by the Texas Senate during the first special
session of the Texas Legislature.
Rathgeber is a past Director of Research for the Texas General Land
Office and a past Director of the Strategic Assessment Division for
the Texas Natural Resource Conservation Commission, now the
Texas Commission on Environmental Quality. Rathgeber received a
bachelor's degree and law degree from the University of Texas at
Austin. She is a member of the State Bar of Texas.
Commissioner Rathgeber spoke at the 21st annual Mid-Year Property
and Casualty Insurance Symposium on July 18, 2013. The event is
sponsored by the Insurance Council of Texas (ICT) and the Association of Fire and Casualty Companies in Texas
(AFACT).
Commissioner Julie Rathgeber
Commissioner Rathgeber said she appreciates the work of the Insurance Council of Texas (ICT) in assisting
the Texas Department of Insurance (TDI) with reviewing and implementing legislation that was passed. She
also said her recent personal experiences with property and casualty insurers after automobile accidents and a
fire at her cabin have been good.
The Commissioner said the Texas insurance industry is huge and sophisticated and she firmly believes her job
is to have staff talent that is faster, smarter, and better service providers. They need skills and professionalism
to deal with the industry. She noted that personal fairness where everyone is treated the same and there is
transparency and an open and accessible TDI is important to her.
Page 8
Commissioner Rathgeber said her focus would be on Texas businesses and consumers to continue to grow the
Texas insurance market. Competition is better for the insurance industry making it easier to regulate in an open
market. She is hoping to attract more companies to the Texas insurance market.
Most Workers’ Compensation Bills Were Not Passed by the Texas Legislature
Out of the 40 workers‘ compensation and workers‘ compensation related bills filed this legislative session, five
bills passed. The bills that were passed by both chambers of the Texas Legislature are:
HB 2645
Relating to certification and operation of independent review organizations.
HB 3152
Relating to the payment of and contracts with health care providers by certain entities
under contract with a certified workers' compensation network.
HB 1762
Relating to workers' compensation and other remedies available to an injured temporary
employee.
SB 381
Relating to the misuse of the name or symbols of the division of workers' compensation of
the Texas Department of Insurance in a deceptive manner.
SB 1322
Relating to the provision of durable medical equipment and home health care services
through informal and voluntary networks in the workers' compensation system; providing
penalties.
Other Legislation That Could Impact Workers’ Compensation Was Also Passed
The Texas Legislature also passed six bills that could have a direct or indirect impact on the Texas workers‘
compensation system. Those bills are:
HB 1055
Relating to the delegation and supervision of prescriptive authority by physicians to
certain advanced practice registered nurses and physician assistants.
HB 1376
Relating to advertising by certain facilities that provide emergency services; providing
an administrative penalty.
SB 227
Relating to the dispensing of aesthetic pharmaceuticals by physicians and therapeutic
optometrists; imposing fees.
SB 406
Relating to the practice of advanced practice registered nurses and physician assistants and the delegation of prescriptive authority by physicians to and the supervision
by physicians of certain advanced practice registered nurses and physician assistants.
SB 1286
Relating to the regulation of professional employer services; authorizing fees.
SB 1643
Relating to the monitoring of prescriptions for certain controlled substances; providing penalties.
The bills that were passed by the Texas Legislature have been or will be referred to Gov. Rick Perry for his
action. The governor has until June 16, 2013 (20 days after the end of the regular session) to sign or veto bills.
The governor may also allow the legislation to become law without a signature.
While the Texas Legislature is in session – in its third special session – insurers and workers‘ compensation stakeholders can go on with their regular business until the next regular session in 2015.
Page 9
Editor’s Note: Albert Betts Jr. is the author of this article. Betts is a partner
with the law firm of Thompson, Coe, Cousins & Irons and ICT’s General
Counsel. Betts focuses his practice on representing the interest of clients
before the Texas Department of Insurance and other regulatory agencies along
with representing the insurance industry, insurance companies, and other
clients before the Texas legislature and other government officials.
Betts has extensive experience as a lawyer and public policy administrator
including representing the Department of Insurance in litigation and the state’s
workers' compensation carrier in administrative proceedings.
Betts has advised the state risk management board, the commissioner of
insurance, and political leadership on insurance and workers’ compensation
matters. Most recently, Betts served as the Commissioner of Workers’
Albert Betts
Compensation for the State of Texas (September 1, 2005 through August
31, 2008 and as Chief of Staff for the Texas Insurance Commissioner.
Betts, who is a lobbyist for the insurance industry and clients, will be speaking at the Insurance Council of
Texas’ workers’ compensation conference on October 3, 2013 and will provide a comprehensive workers’
compensation legislative review. His presentation will include a discussion of the political landscape in Texas
and workers’ compensation legislation that was filed and considered by the Texas Legislature.
Insurance Industry’s Privileged Communications Legislation Falls Short and is Not Passed
Legislation to address the Texas Supreme Court‘s
decision in In Re XL Specialty Insurance Company
and Cambridge Integrated Services Group (XL
Specialty) – House Bill (HB) 1468 – did not pass
during the 2013 legislative session. HB 1468 was
voted out of the Texas House of Representatives
(House) Business & Industry Committee but never
made it out of the House Calendars Committee.
The Supreme Court ruled in ruled in the XL
Specialty court case that communications made
between an insurer's attorney and the employer
during a workers‘ compensation administrative
proceeding is not attorney-client privilege communications. The court also ruled that such communications are subject to discovery.
HB 1468 proposed amending Chapter 409 of the Texas Labor Code by adding Section 409.025 and providing
that these communications are confidential and privileged under the Texas Labor Code.
Continued on next page.
Do Not Forget to Register for ICT’s Oct. 3, 2013 Workers’ Compensation Conference
Registration is available online at http://www.insurancecouncil.org/workersComp/workersCompAgenda?id=1
Page 10
Insurance Industry Disappointed That HB 1468 Did Not Pass
Trey Gillespie, Senior Workers Compensation Director for the Property
Casualty Insurers Association of America (PCI) expressed disappoint
that HB 148 was not passed.
―PCI is disappointed that the XL Specialty bill was not passed by the
Texas Legislature this session,‖ said Gillespie. ―The bill would have
protected the confidentiality of limited communications between the
carrier and the policyholder.‖
Trey Gillespie
Gillespie noted that this type of confidentiality exists in almost all other
states and would have been no greater than the confidentiality that exists
for communications between an injured worker and Ombudsmen
employed by the Office of Injured Employee Counsel.
Gillespie said, ―This level of confidentiality is critical to providing good service to policyholders and facilitates
efficient resolution of disputed issues in the claims process.‖
Albert Betts, a lobbyist for the Association of Fire and Casualty
Companies of Texas and general counsel for the Insurance Council
of Texas, said the failure of HB 1468 to pass this session, means
that employers will have to make decisions about how they want to
handle communications with the counsel for their insurers.
Albert Betts
―The lack of a legislative fix to the XL Special decision means that
employers will have to make decisions about how they want to handle
communications with the counsel for their insurers,‖ said Betts.
―Employers and counsels for insurers will either have to only engage in
very generic non-legal and non-strategy discussions about the claim,
basically, a "just the facts, ma'am" approach, or they will have to enter into
agreements for joint defense with carrier counsel or retain their own
counsel for the workers‘ compensation claim.‖
Betts said failure to pass HB 1468 it stifles legitimate information sharing between the injured worker's
employer and the insurance carrier's attorney as the dispute progresses through the Division of Workers‘
Compensation dispute resolution process and beyond.
―Employers will no longer feel comfortable asking "how's the claim going" or "what do you think happens
next", because the attorney will be concerned about providing information that may be discoverable by
opposing counsel,‖ said Betts.
Best noted that, ―HB 1468 was never about stopping the disclosure of factual information about the claim or
information pertinent to determining whether a disputed claim was compensable. It was about ensuring that
communication that had happened for years between the employer, who is paying the workers' compensation
premium and is the policyholder, could talk freely with the lawyer representing the insurance company
handling the claim.‖
Page 11
Texas Labor Spokesperson Weighs in on the Client Attorney Privilege Issue as related to Communications
Between Insurers’ Attorney and Injured Employee’s Employer
Richard Levy, Legislative Counsel for the Texas AFL-CIO, said that
he does believe the failure of HB 1468 not passing will have much of
an impact on the Texas workers' compensation system.
"Bad faith claims are not a real growth industry in Texas and certainly
are no longer a real motivator for anyone in the system," said Levy.
"The Division of Workers' Compensation continues to be able to get
information for administrative purposes and proceedings."
Levy said that it possible that there will continue to be some sense by
insurer's counsel and employers that they can't improperly collude
with impunity to deny a claim.
Rick Levy
"I am not sure that is such a horrible thing," noted Levy. The Texas
AFL-CIO believes that predictions of negative impact on the system
due to failure of the bill to pass are overblown."
Levy said that stakeholders in the Texas system have much more important things that motivate their behavior.
He noted that the Texas AFL-CIO believe that the Texas Supreme Court's decision in the XL Specialty case
was an appropriate decision that should not be overturned via legislation.
Will There be Future Legislation to Fix the XL Specialty Decision?
Insurers and Texas employers believe that privileged communication is necessary when an employer and
insurance company attorney discuss legal issues associated with a workers‘ compensation claim and/or dispute
resolution strategies. As such, it is likely that Texas workers‘ compensation stakeholders will witness the filing
of legislation similar to HB 1468 during the 2015 legislative session.
Employers and insurance carrier attorneys are already considering how to approach communicating about
workers‘ compensation claims without the passage of HB 1468. Time will tell how this issue is handled and if
the projected impact of the failure to pass HB 1468 is overblown as argued by the Texas AFL-CIO or if there
will be a negative impact on the Texas workers‘ compensation system as argued by employers and insurance
company attorneys.
Legislation to Covert Texas Mutual Into an Independent Mutual Insurance Company Not Passed
Legislation intended to convert Texas Mutual Insurance Company (Texas Mutual) into an independent mutual
insurance company that elects its board of directors and create an assigned risk pool workers‘ compensation
was one of many workers‘ compensation bills that did not pass during the recent legislative session. Both bills,
Senate Bill (SB) 850 filed by Senator Larry Taylor (R-Friendswood) and House Bill (HB) 1833 which was
filed by Representative Kenneth Sheets (R-Dallas), did not pass out of their respective legislative chamber.
The legislation, which was set to be effective on Jan. 15, 2015, would have made Texas Mutual a private
insurance carrier and required the commissioner of insurance to establish an assigned risk plan for the workers‘
compensation residual market and approve a plan of operation for the assigned risk program. The
Page 12
legislation also provided that provides that TDI could contract with a licensed stat agent for workers‘
compensation to administer the plan. Several members of the Texas Legislature expressed concern about this
provision of the legislation.
The attempt by Texas Mutual to sever their few remaining statutory ties with the State of Texas was part of a
Long Term Vision (LTV) that the company had adopted. Texas Mutual noted in its Fall 2012 edition of its
newsletter that pursuing the LTV was in the best interests of their policyholders and the Texas workers‘
compensation system as a whole.
Texas Mutual noted in its newsletter that the move to sever their remaining statutory ties with the State of
Texas would protect their policy holders‘ company by eliminating the potential for the ―ever-changing
dynamics of the…[Texas]…political system…[that could]…be a destabilizing factor‖ as the statutory ties
make the company ―vulnerable to dictates driven by political agendas.―
Texas Mutual also noted that by severing its statutory ties to Texas, the policy holders of the company would
have the power to elect all nine of its board members from any industries they see fit. Currently, the Governor
of Texas appoints five members of Texas Mutual‘s board of directors and its policy holders elect the other four
members of the board of directors.
Texas Mutual reported in its Fall 2012 newsletter that they believed Texans deserve a residual market that is
stronger than a single carrier. By law, Texas Mutual writes all residual market policies for Texas employers.
Texas Mutual proposed that all insurance carriers should share the residual market.
Since the legislation did not pass, Texas Mutual will continue to operate as they have since the company
started writing workers‘ compensation insurance policies in 1992 as the Texas Workers‘ Compensation
Insurance Fund. Texas Mutual will also continue to serve as the only writer of residual market policies.
About Texas Mutual Insurance Company
The Texas Workers‘ Compensation Insurance Fund was created by the Texas Legislature with the passage of
SB 1 during the 1989 legislative session to ensure the availability and affordability of workers' compensation
coverage. In 1992, the Fund began writing workers' compensation insurance. In 1994, Texas Mutual became
the state's insurer of last resort for businesses that were unable to find coverage elsewhere.
On June 15, 2001, Governor Rick Perry signed HB 3458 into law, changing the company's name to Texas
Mutual Insurance Company and authorizing the company to operate as a domestic mutual insurance company
(with continued political oversight by the state). The bill maintained statutory mandates that the company
remain a competitive force in the marketplace, guarantee the availability of workers' compensation insurance
in Texas, and act as insurer of last resort.
Texas Mutual is governed by a nine-member board of directors. Four board members are elected by the
policyholders, and the remaining five board members, including the chair, are appointed by the governor and
confirmed by the Senate. The board is responsible for setting rates and directing the company's business. The
company's senior leadership manages its internal operations.
Texas Mutual currently writes approximately 33 percent of the workers‘ compensation policies in the Texas
workers‘ compensation system and is considered to be owned by its policy-holders and annually distributes
dividends to its policy holders. In 2012, Texas Mutual distributed $150 million in dividends among approximately 41,000 qualifying policyholder owners. Texas Mutual has distributed dividends totaling $1.2 billion
since the company started distributing dividends in 2005.
Page 13
THOMPSON
COE
Austin
Dallas
Houston
Saint Paul
Celebrating 60 Years of Service
Since 1951, Thompson, Coe, Cousins & Irons, L.L.P. has dedicated itself to providing clients with responsive
and quality legal services. It has grown from a firm of two experienced practitioners in property and casualty
insurance law to a firm of over 120 attorneys with offices in Austin, Dallas, Houston and Saint Paul.
Thompson Coe is nationally recognized by the insurance industry for its expertise in insurance law and for its
litigation skills. In recent years, the firm has expanded its capabilities in workers‘ compensation law. The
firm‘s clients are varied. The firm has represented clients in trial and appellate courts in both the state and
federal system and before state agencies include the Texas Department of Insurance, the Division of Workers‘
Compensation and the Texas Legislature.
The firm maintains a legislative practice, representing principally insurance industry clients, including the
Association of Fire and Casualty Companies in Texas (AFACT). The firm is counsel to several insurance
industry trade associations, including the Insurance Council of Texas (ICT), who work with the Texas
Department of Insurance concerning rules, rates and forms with respect to all lines of property and casualty
insurance.
Thompson Coe also represents insurers in workers‘ compensation claims dispute matters before the Texas
courts.
The firm‘s litigation practice include contract disputes, coverage questions under property and liability
policies, defense against fraud and bad faith claims, business litigation, subrogation and intervention actions
and workers‘ compensation.
THOMPSON, COE, COUSINS & IRONS, LLP
SINCE 1951
Insurance Regulatory and Transactions Section
ALBERT BETTS JR.
[email protected]
(512) 703-5039
RODNEY D. BUCKER
[email protected]
(214) 871-8255
JACK M. CLEAVELAND JR.
[email protected]
(214) 871-8280
WILL D. DAVIS
[email protected]
(512) 703-5070
RICHARD S. GEIGER
[email protected]
(214) 871-8281
MICHAEL W. JONES
[email protected]
(512) 703-5055
DAVID D. KNOLL
[email protected]
(512) 703-5090
JAY A. THOMPSON
[email protected]
(512) 703-5060
EMORY L. WHITE JR.
[email protected]
(214) 871-8282
Visit Thompson Coe Online at www.thompsoncoe.com.
Page 14
Announcing ICT’s 2013 Workers’ Compensation Conference
The State of the Texas Workers' Compensation System: The
Chief Regulator's Perspective – Rod Bordelon,
Commissioner of Workers‘ Compensation
2013 Workers' Compensation Legislation Update – Albert
Betts, Partner at Thompson Coe and General Counsel of the
Insurance Council of Texas
Survey of Workers' Compensation Research Findings –
D.C. Campbell, Director, TDI Workers‘ Compensation
Research & Evaluation Group
A National Perspective on Workers' Compensation: How
Texas Compares – Todd K. Brown, Director of Compliance
and Regulatory Affairs, EK Health Services®, Inc.
Workers' Compensation Panel Discussion: Hot Button
Workers' Comp Issues – Moderated by Stuart Colburn,
Shareholder, Downs Stanford, P.C.
Panelists:
Thursday, October 03, 2013
Omni Austin Hotel
4140 Governor's Row
Austin, Texas
Register Online Here
Sponsorship Opportunities Available
Contact Steve Nichols at 512.786.3946 or
[email protected] for information
about sponsorship opportunities.
Rod Bordelon, Commissioner of Workers‘ Compensation
Cathy Stoebner DeWitt, Texas Association of Business
Trey Gillespie, Senior Workers Compensation Director,
Property Casualty Insurers Association of America
Rick Levy, Legal Director, Texas AFL-CIO
On the Horizon: Treatments and Devices that are Making a
Difference – Moderated by Tron Emptage, Rph, Chief
Clinical Officer, Progressive Medical
Panelists:
Robert Hall, M.D., Medical Director, Progressive Medical
Brian Buck, M.D., Medical Director, TASB Risk
Management Services
Utilization Review and Peer Reviews in the Texas Workers'
Compensation System – Jane Stone, Partner, Stone Loughlin
& Swanson, L.L.P.
P.O. Box 15
Austin, Texas 78767-0015
Phone – 512.444.9611 ● Fax No. – 512.444.0734
Page 15
Ron Cobb, counsel to the American Insurance Association
(AIA), was presented the Raymond Mauk Leadership Award
Thursday, July 18, in Austin, at the 21st Annual Mid-Year
Property and Casualty Symposium. Cobb becomes the
sixteenth recipient of the prestigious award.
Ron Cobb and Joe Johnson, United Fire Group
and Chairman of ICT’s Board of Directors
The Insurance Council of Texas (ICT) presents the Raymond
Mauk Leadership Award at its Mid-Year Property and Casualty
Insurance Symposium each year. It is the Council‘s highest
honor and is intended to bestow recognition on those whose
labor has made a significant difference in the business of
insurance.
Cobb was recognized for his major role in helping to reform the
Texas workers‘ compensation system, resolving premium and maintenance tax issues and moving the state
away from a promulgated rate making system to the more competitive file and use marketplace that
hasbenefited companies, agents and policyholders.
At age 20, Cobb worked as a personal lines underwriter for USF&G. Two years later, he began work at
American General, first in personal lines and then became a manager for commercial lines.
At 26, Cobb was elected president of the Houston Texas Jaycees and in one year, he helped build that
organization into one of the nation‘s largest chapters. Upon taking office, he went to then Houston Mayor
Louie Welch and asked what project he could take on that would make the biggest difference. Welch suggested
the toughest project that he knew of, was to somehow get fresh water to a small African-American community
that was located within one half mile of the Houston Intercontinental Airport. The residents of Bordersville
paid city taxes, but didn‘t even have basic city services. Cobb helped rectify the situation by coordinating a
water well drilling project that was recognized nationally as the best Jaycee project of the year.
After graduating from high school, Cobb spent the next 11 years working during the day and at night, attending
the University of Houston and eventually graduating from the South Texas School of Law. With his law degree
Cobb was named assistant counsel for American General and put in charge of government affairs. It was at this
point in his career that he began attending insurance industry meetings in both Austin and Dallas.
In 1976, after spending 12 years with American General, Cobb was hired as regional vice president with the
American Insurance Association (AIA) where he assumed responsibility for eight states.
In 2003, Cobb retired as regional vice president and began serving as counsel to AIA and other industry
organizations. In his current role as counsel to AIA and other insurance industry organizations, Cobb represents
insurance industry interests on issues that range from automobile and homeowners insurance, the Texas
Windstorm Insurance Association and workers‘ compensation.
In 2012, Cobb played a significant role in the preparation for and hosting of the Insurance Council of Texas‘
luncheon that honored the Texas insurance industry‘s World War II veterans. Cobb spent many hours researching and identifying past insurance industry executives and professionals who served in World War II so that
they could be recognized during the luncheon. He also loaned a large collection of World War II artifacts and
era magazines for an exhibit about the war that was displayed at the conference.
Page 16
About the Award
The Raymond Mauk Award honors former Texas Fire Commissioner Raymond Mauk and annually recognizes
someone who has made a notable contribution to the Texas property and casualty insurance industry.
Mauk enjoyed a long and distinguished career and held many positions of leadership within his company and
industry organizations.
More than 70 years ago, Commissioner Mauk was convinced that fundamental change was needed to protect
the insurance buying public and the integrity of the marketplace from the misapplication of rates and forms.
To accomplish his goal, Mauk envisioned the creation of a central checking office that would enforce good
business practices and audit the insurance industry‘s paperwork for errors and competitive greed. Faced with
opposition and a resistance to change, Mauk labored for two years to build support from both agents and
companies.
By February 1935, Mauk‘s leadership had led to the successful establishment of the Texas Insurance Checking
Office, an institution, which continues to serve the Texas industry today.
Gov. Perry Announces He Will Not Seek an Additional Term in Office
Gov. Rick Perry, who will have been in office for
more than 14 years when his term ends in January
2015, announced on July 8, 2013 that he will not
run for re-election next year. Gov. Perry said it was
time to pass on the mantle of leadership.
"I remain excited about the future and the
challenges ahead, but the time has come to pass on
the mantle of leadership," Perry said. "Today I am
announcing I will not seek re-election as governor
of Texas. I will spend the next 18 months working
to create more jobs, opportunity and innovation. I
will actively lead this great state."
Perry was elected Lieutenant Governor of Texas in 1998 and assumed the Texas governorship in December
2000 when then-governor George W. Bush resigned to become President of the United States. Perry was
elected to full gubernatorial terms in 2002, 2006 and 2010 and is the fourth Texas governor (after Allan
Shivers, Price Daniel and John Connally) to serve three terms.
Perry's decision not to run for a fourth full term will usher in a new era in Texas politics. For the last two
decades, the governor's mansion has been in the hands of two politicians, George W. Bush and Perry. Gov.
Perry‘s decision to not run creates an open race for the Texas Governorship and making Attorney General Greg
Abbott the instant favorite to replace him.
Is Gov. Perry Contemplating a Second Run for the White House?
Perry‘s announcement that he would not be running for another term as Texas Governor sparked talk that he
may be considering another run for the White House. He unsuccessfully ran for the Republican nomination for
President in 2012.
Page 17
The National Review reported in May 2013 that Texans close to Perry have reported that ―he‘s strongly
considering a presidential run.‖ David Carney, who was Perry‘s top adviser during his 2012 presidential bid,
tells me that ―there‘s no question‖ that Perry is seriously weighing the prospect of a 2016 run; it‘s not just talk.
Perry has not ruled out running for President in 2016. In fact, he said that he would decide what he will do next
at a later date. "Any future considerations I will announce in due time, and I will arrive at that decision
appropriately," Perry said.
Perry Played Key Role in the Passage of Legislation That Has Reformed and Transformed the Texas
Workers’ Compensation System
House Bill (HB) 7, an omnibus workers‘ compensation bill that overhauled the Texas workers‘ compensation
system in 2005, was passed while Gov. Perry was serving his first elected term as Governor. Perry backed the
passage of workers‘ compensation reform legislation which he thought to be key to attracting new businesses
to Texas.
Perry applauded the passage of HB 7 in 2005 and stated, ―This bill will help create thousands of new jobs for
our families as employers continue to flock to Texas for our excellent business climate.‖
Gov. Perry Vetoes Bill That Would Have Allowed Physician Dispensing of Cosmetic Drugs
On June 14, 2013, Texas Gov. Rick Perry vetoed Senate Bill (SB)
227. SB 227, which was passed during the regular session of the 83rd
Texas Legislature, would have allowed physicians and therapeutic
optometrists to dispense aesthetic pharmaceutical drugs to their
patient‘s in excess of the patient's immediate needs without obtaining
a license to practice pharmacy. The bill, which was filed by Sen.
Tommie Williams (R-The Woodlands) also authorized physicians
and therapeutic optometrists to charge a fee for dispensing the
pharmaceutical.
Gov. Perry said he vetoed the bill due to concerns about the lack of
safety protocols and oversight for the drugs in question that would be
dispensed by a physician or optometrist.
―SB 227 would circumvent existing safeguards for the dispensing of
certain prescription cosmetic drugs by allowing physicians and
optometrists to sell these medications directly,‖ said Gov. Perry. ―It is the role of pharmacists - who are trained
specifically in drug interactions, side effects and allergies - to dispense the medications.”
Gov. Rick Perry
Gov. Perry noted that the State Board of Pharmacy has the authority to inspect pharmacies to ensure drugs are
stored securely and at safe temperatures and noted that there was no such oversight provided for by SB 227.
―I share concerns from within the health care community that though these drugs are used for aesthetic
purposes, they are still prescription-strength drugs with potentially dangerous side effects and interactions, and
therefore should remain subject to existing safety protocols and oversight,‖ said Perry.
Our Workers’ Compensation Newsletter is Available at No Cost to ICT Member and Associate Member Employees
ICT member and associate member employees can contact ICT‘s webmaster to request access the newsletter.
Page 18
Gov. Perry Signs Several Workers’ Compensation Related Legislation into Law
Texas Governor Rick Perry has been busy signing and vetoing legislation passed during the regular session of
the 83rd Texas Legislature. Among the legislation Gov. Perry has signed into law are 6 workers‘ compensation
bills.
The bills signed by Gov. Perry include House Bill (HB) 581 relating to the waiver of sovereign immunity in
certain employment lawsuits by nurses, HB 1762 relating to workers' compensation and other remedies
available to an injured temporary employee, HB 2645 relating to certification and operation of independent
review organizations, HB 3152 relating to the payment of and contracts with health care providers by certain
entities under contract with a certified workers' compensation network, Senate Bill (SB) 381 relating to the
misuse of the name or symbols of the division of workers' compensation of the Texas Department of Insurance
in a deceptive manner, and SB 1322 relating to the provision of durable medical equipment and home health
care services through informal and voluntary networks in the workers' compensation system.
Gov. Perry had until June 16, 2013 to sign or veto legislation that was passed during the regular session of the
83rd Texas Legislature. Any legislation without specific effective dates (that could not be effective
immediately) that are neither signed nor vetoed by Gov. Perry become law on August 26, 2013. There was no
workers‘ compensation legislation not signed by Gov. Perry.
NCCI Names Katherine Antonello, FCAS, MAAA, as Chief Actuary
On July 8, 2013, NCCI announced the appointment of Katherine Antonello, FCAS, MAAA, to the position of
chief actuary. Ms. Antonello succeeds Dennis Mealy, who is retiring after 11 years of service.
"We are very pleased to announce Kathy Antonello's appointment as our next chief actuary," said NCCI
President and CEO Steve Klingel. "She has a broad and accomplished professional background, including a
distinguished record of actuarial achievement and senior management success. While we are going to be very
sorry to lose Dennis to a well-earned retirement, we are confident that we have found a highly capable
individual to succeed him."
"It's a tremendous honor to be named as NCCI's new chief actuary," Ms. Antonello said. "NCCI is well known
throughout the workers compensation industry for their highly trained and professional actuaries and
economists, and I am delighted to have the opportunity to join such a skilled and respected team."
As chief actuary, Antonello will be responsible for leading the Actuarial and Economic Services division at
NCCI. The division is responsible for all actuarial and economic work, including rate/loss cost filings,
legislative analyses, compilation and analysis of insurance industry results, residual market reserving, actuarial
products, and producing topical industry research. As a member of the senior management team, she will
actively participate in the development and implementation of NCCI's corporate objectives and strategies.
Antonello spent the past 12 years at Lumbermen's Underwriting Alliance, a multi-line carrier writing a
significant number of large workers compensation accounts. Her executive responsibilities included over-sight
of all workers compensation activities including claims, regulatory affairs, policy issuance, data reporting, and
reinsurance, in addition to the chief actuary corporate role. previously worked as an actuary with Liberty
National Life Insurance Company and Milliman & Robertson. For five years in the late 1990s, she was
employed as an actuary in NCCI's Actuarial and Economic Services Division. She has a BS in mathematics
from Birmingham-Southern College.
Page 19
Collective Years of Legal Experience
SMITH & CARR, P.C.
ATTORNEYS AT LAW
More Information About the Firm
(Right Click on Information Topics)
Smith & Carr, P.C. Attorneys
Representative List of Clients
Seminars Offered by Smith & Carr, P.C.
Onsite Continuing Education
SMITH & CARR, P.C. is a litigation boutique founded by Stephen T. Smith and
Charles M. Carr, III. Their collective years of legal experience provide a
background for the handling of claims in both judicial and administrative forums,
as well as the alternative dispute resolution process.
Smith & Carr, P.C. is dedicated to providing efficient economical and aggressive
representation of its clients in both litigation and administrative matters. The firm's
strength lies in its collective years of legal experience together with a solid work ethic
based upon the belief that providing cost effective legal representation is paramount. The
firm's attorneys concentrate on trials and appeals in state and federal court, as well as
before administrative tribunals.
SMITH & CARR, P.C. Primarily handles personal injury defense (insurance defense),
insurance coverage, employment and commercial issues. Areas of practice include:
Employment:
Insurance:
Personal Injury:
Defense of employers in litigation involving
Americans With Disabilities Act, Fair Labor
Standards Act, Family Medical Leave Act,
Hour/Wage and Unemployment claims, Retaliatory
Discharge and Wrongful Termination.
Defense of insurance carriers in Bad Faith and
Deceptive Trade Practices/Consumer Protection
litigation, Coverage Opinions, Declaratory Judgment
Actions, and Insurance Subrogation.
Defense of insured's in litigation involving
Automobile, Construction Liability, Employer's
Liability, Jones Act/Maritime, Longshore and Harbor
Workers' Compensation Act, Defense Base Act,
Premises Liability, Products Liability, Trucking and
Workers' Compensation.
Professional Injury: Accounting, Insurance Agent and Insurance Claims Malpractice.
Not Certified by the Texas
Board of Legal Specialization
The attorneys of SMITH & CARR, P.C. are licensed to practice law in the courts of the
States of Texas, Louisiana and Oklahoma. They are also licensed in federal courts in
Texas and Louisiana.
Smith & Carr, P.C.
4900 Woodway, Suite #1200
Houston, Texas 77056
Phone: 713.933.6700
Facsimile: 713.933.6799
Email : [email protected]
Website: www.smithcarr.com
An Associate Member of the Insurance Council of Texas
Page 20
Page 21
Texas Legislature Passes Legislation Authorizing Informal and Voluntary
Networks for Durable Medical Equipment and Home Health Care Services
Legislation authorizing informal and voluntary networks for durable
medical equipment and home health care services was passed by the 83rd
Texas Legislature and sent to Texas Gov. Rick Perry for his signature. The
Texas Legislature passed Senate Bill (SB) 1322, authored by Sen. Leticia
Van de Putte (D-San Antonio), on May 26, 2013 and sent to Gov. Rick
Perry on Mary 27, 2013.
SB 1322 authorizes an insurance carrier to pay a health care provider fees
for durable medical equipment or home health care services that are
inconsistent with the fee guidelines adopted by the commissioner only if
the carrier or the carrier's authorized agent has a contract with the provider
that includes a specific fee schedule.
The bill also authorizes an insurance carrier or the carrier's authorized
agent to use an informal or voluntary network in order to obtain a contractual agreement providing for fees different from those authorized under the fee guidelines adopted by the
commissioner for durable medical equipment or home health services.
Sen. Leticia Van de Putte
SB 1322 specifies that "durable medical equipment" includes prosthetics and orthotic devices and related
medical equipment and supplies, but does not include an object or device that is surgically implanted,
embedded, inserted, or otherwise applied, related equipment necessary to operate, program, or recharge such
an object or device, or an intrathecal pump.
Contractual Agreement Between Insurance Carrier or Authorized Agent and Network Required
SB 1322 requires a contractual arrangement to exist between the insurance carrier or authorized agent and the
informal or voluntary network authorizing the network to contract with health care providers for durable
medical equipment or home health care services on the insurance carrier's behalf and also requires such a
contractual arrangement between the informal or voluntary network and the health care provider that includes a
specific fee schedule and complies with the notice requirements prescribed by the bill. The legislation also
requires an insurance carrier, or the insurance carrier's authorized agent or an informal or voluntary network at
the carrier's request, to provide copies of each such contract to the Texas Department of Insurance‘s Division
of Workers' Compensation (DWC) on the request of the DWC and makes such information confidential and
not subject to disclosure under public information law. The bill additionally establishes that the insurance
carrier may be required to pay fees in accordance with the DWC's fee guidelines if the contract is not provided
to the DWC on the DWC's request, does not include a specific fee schedule consistent with the bill's
provisions, or does not clearly state that the contractual fee arrangement is between the health care provider
and the named insurance carrier or the insurance carrier's authorized agent, or if the insurance carrier or the
insurance carrier's authorized agent does not comply with the bill's notice requirements.
Quarterly Notification Required When Network’s Contractual Fee Arrangements Are Sold, Leased, or
Transferred
SB 1322 also requires an informal or voluntary network, or the carrier or the carrier's authorized agent, to notify
each health care provider at least quarterly of any person, other than an injured employee, to which the network‘s
contractual fee arrangements with the health care provider are sold, leased, transferred, or conveyed.
The bill sets out the required contents and the authorized methods of delivery for the notice. The bill requires an
informal or voluntary network, or the insurance carrier or the insurance carrier's authorized agent, as appropriate, to
Page 22
document the delivery of the notice and establishes the conditions under which notice is considered to be delivered.
The bill requires a contractual agreement described by the bill that is entered into after the bill's effective date to be
sent not later than the 30th day after the effective date of the contract with subsequent notices to be sent on a
quarterly basis.
SB 1322 establishes that failure to provide appropriate documentation requested by the DWC or failure to
provide notice as required by the bill creates a rebuttable presumption in an enforcement action under the Texas
Workers' Compensation Act and in a medical fee dispute that a health care provider did not receive the notice.
The legislation provides that an insurance carrier or the insurance carrier's authorized agent commits an
administrative violation if the insurance carrier or agent violates any of the bill's provisions relating to
reimbursement for durable medical equipment and home health care services. The bill requires any administrative penalty assessed under the bill to be assessed against the insurance carrier, regardless of whether the
insurance carrier or agent committed the violation. The bill establishes that its amendments to the Texas Labor
Code prevail in the event of a conflict with any provisions in the Texas Workers' Compensation Act governing
medical review or any provisions in the Insurance Code governing workers' compensation health care networks.
The bill does not expressly grant any additional rulemaking authority to the Texas Department of Insurance or
the Division of Workers‘ Compensation.
Work Loss Data Institute Releases Opioid Outreach Flyer
Work Loss Data Institute
On June 6, 2013, Work Loss Data Institute (WLDI) announced the
release of a free opioid flyer summarizing key evidence-based
takeaways from Official Disability Guidelines (ODG) and the ODG
Drug Formulary for outreach to healthcare providers, health plans and
officials in State workers‘ comp systems, Medicare and Medicaid.
―The Centers for Disease Control and Prevention has urged states to
ensure providers follow evidence-based treatment guidelines for the
safe and effective use of prescription painkillers, said Phil Denniston,
President and CEO of WLDI. ―WLDI was asked by clients to create
the document for distribution by payers and workers‘ compensation
authorities to providers active in their system.‖
Deaths from opioid pain relievers now far exceed those from heroin and cocaine, and the risks of overdose and
death increase significantly with higher doses. Almost 90% of misuse and abuse comes from drugs prescribed
legally to users or their friends and family, mostly from primary care and internal medicine doctors, not
specialists.
The flyer aims to educate providers on appropriate use and dosage of opioids for acute, sub-acute and chronic
pain, including recommendation of a two-week limit for acute pain, and a one month limit for non-malignant
chronic pain patients. Guidance outlines 10 critical steps to take before prescribing a therapeutic trial of opioids,
and evidence-based criteria for both when to continue and when to discontinue opioid therapy.
The ODG Drug Formulary for opioids is also included, indicating which opioids should be considered first-line
(Y) in carefully selected cases vs. those that should not (N).
―Simply put, we need to stop this problem in its tracks‖ said Denniston. ―Evidence-based medicine through
provider education is the way to do it‖.
Page 23
Following adoption of the ODG Drug Formulary in Texas, fewer ―not recommended‖ (N) drugs are being
prescribed in the workers‘ comp system according to a recent study by the Department of Insurance, Division of
Workers‘ Comp and the Workers‘ Comp Research and Evaluation Group. Drug costs attributed to N drugs are
down 75%, while the prescription frequency is down 65%. Total drug costs are down 26%.
Commenting on the study, Commissioner Rod Bordelon said, ―This is significant. With this formulary, along
with treatment guidelines, preauthorization requirements and enforcement efforts, Texas is now leading the
charge in combating overutilization of unnecessary prescription drugs in workers‘ comp, while safeguarding
medically necessary care that promotes an injured employee‘s return to work quickly and safely.‖'
The flyer can be found at: http://odg-disability.com/odgopioidflyer.pdf.
ODG leverages evidence-based clinical criteria into actionable medical management intelligence to support
optimal clinical and return-to-work outcomes. With a multidisciplinary team of physicians and a comprehensive
literature review and ranking process, ODG provides a unique and proprietary web-based tool for utilization
review, return-to-work decision support, claims reserving and case management.
WLDI is an independent database development company focused on workplace health and productivity, based
in Encinitas, California, founded in 1995.
Well Respected Former DWC Work Place Safety Expert Passes Away
Robert Giacomazza, a well respected work place safety expert and former
employee of the Texas Workers‘ Compensation Commission (TWCC) and
Division of Workers‘ Compensation (DWC), passed away on June 11,
2013 after a 7 month battle with cancer. Giacomazza, who served in the
U.S. Air Force and retired as Lieutenant Colonel after 20 years of service,
focused on work place safety when he started his second career.
Giacomazza was highly thought of by his peers and those he worked with
at TWCC and the DWC. Robert M. Marquette, former Director of the
Medical Review Division and Division of Workers‘ Health & Safety at
TWCC expressed sentiments shared by many of Giacomazza‘s peers.
―I was disappointed and sad to learn of his passing. He was a very good man and an excellent worker and
professional,‖ said Marquette. ―I enjoyed having him on my team. He was one of the good guys.‖
Giacomazza was born in Brooklyn, New York, raised in Tucson, Arizona and lived in Austin, Texas and Cedar
Park, Texas for 35 years. He attended and graduated from the University of Arizona before joining the U.S. Air
Force as an officer.
Giacomazza is survived by his fiancé Cecilia Wibbelsman, his son Daniel (Kerry), and their daughters, Sophia
and Hope, his son Philip (Leslie), granddaughter Angelina Giacomazza, and sisters Nancy Davis and Joan
Harris.
Bob was loved by his family and many friends. His family said he was taken all too soon and will be truly
missed.
A memorial service was held on July 19th at the Hill Country Bible Church in Austin, Texas. His family
requested that donations be made to Hospice Austin in lieu of flowers.
Page 24
Commissioner of Workers’ Compensation Appoints New Medical Advisor
On August 16, 2013, the Commissioner of Workers‘ Compensation, Rod Bordelon, announced that he has
appointed Dr. David Davis as the Medical Advisor for the Texas Department of Insurance, Division of
Workers‘ Compensation (DWC), effective August 26, 2013.
In accordance with the Texas Labor Code the DWC employs a medical director to advise the Commissioner of
Workers‘ Compensation on the adoption of rules and policies. The Medical Advisor also reviews complaints
on quality of care and serves as the chair of the Medical Quality Review Panel (MQRP), which reviews the
actions of doctors, other health care providers, insurance carriers, utilization review agents and independent
review organizations in the workers‘ compensation system.
Dr. Davis has more than 40 years of experience in orthopedic surgery including orthopedic reconstructive
surgery, hand surgery and sports medicine. He retired from his 20 year Austin-based practice in 2012.
Previously, he practiced as an orthopedic surgeon in California from 1979 to 1992, and is a member of the
American Academy of Orthopaedic Surgeons. Dr. Davis attended medical school at the University of Texas
Medical School at San Antonio and received additional Orthopedic Surgery training at Loma Linda University
Medical Center in Loma Linda, California.
During this past year, he has served as a member of the DWC MQRP as a case reviewer, participated in
informal settlement conferences, attended quarterly arbiter meetings, provided MQRP training and assisted in
the development of plan-based audits. Dr. Davis has also reviewed designated doctor applications for
certification and recertification and assisted with designated doctor questions. He has participated in the
designated doctor program since 2004.
Former DWC Medical Advisor Dr. Donald Patrick, who was appointed in July 2010, will continue his service
at the DWC as a Special Advisor to the Commissioner of Workers‘ Compensation.
Amended Rules Regarding Certification of MMI and Evaluation of Permanent Impairment Adopted
On August 5, 2013 the Commissioner of Workers‘ Compensation Rod Bordelon adopted amended 28 Texas
Administrative Code (TAC) §130.1, regarding certification of maximum medical improvement and evaluation
of permanent impairment.
The purpose of the adopted rule amendments is to clarify the consequence of noncompliance with 28 TAC
§130.1(c)(3). The amendments clarify that an impairment rating is invalid and therefore not adoptable if it is
based on a date that is not the maximum medical improvement (MMI) date, which is the Division of Workers‘
Compensation‘s longstanding interpretation of the rule. These amendments further clarify that an impairment
rating and its corresponding MMI date must be included in the DWC Form-069, Report of Medical Evaluation,
to be valid.
A copy of the adopted rule, as amended, is available on the Texas Department of Insurance website at
http://www.tdi.texas.gov/wc/rules/adopted/index.html.
Do Not Forget to Register for ICT’s Oct. 3, 2013 Workers’ Compensation Conference
Registration is available online at http://www.insurancecouncil.org/workersComp/workersCompAgenda?id=1
Page 25
Catastrophic Case Management: An Inside Look
By Michele Ritchie, Marketing Communications Manager for GENEX
Fires…explosions…serious car accidents…traumatic brain
injuries. These are the tragedies you see on the news, or perhaps you
know someone who has experienced serious injury. But for
catastrophic case managers, they handle the most tragic and severe
injuries on a daily basis. We wanted to find out just what happens in
a catastrophic case, so we sat down with some of our Catastrophic
Case Managers. Prepare to be enlightened, and have your tissues
handy!
An Amazing Comeback
―Help! Help! Somebody help me!‖ screamed the little girl on the
front lawn. ―The house is on fire and my grandmother is inside!
Please help!‖ John Riggs*, out on his package
delivery route, pulled over and ran inside the house full of smoke. After locating the grandmother at the back
end of the house, he carried her to the front door, just as the fire department arrived. Then, as he opened the
door to bring her out, a back draft occurred which ignited flames around them, burning them both severely.
Sadly, the grandmother did not survive her injuries.
Diane Hamilton, GENEX Catastrophic Nurse Case Manager, received the call that she was needed at The Burn
Center at The Medical College of Virginia. ―I went to the center to assess his condition, and to let his family
know that I would be coordinating John‘s care, and be there for them,‖ said Hamilton. Hamilton was informed
by the medical staff that Riggs had suffered second- and third-degree burns to 40% of his body, primarily on
his torso, arms, and face. He was also put on a ventilator, IVs, and tube feedings for two months. When he was
ready to be discharged, Hamilton coordinated Riggs‘ home health care and DME needs, as well as his treatment by the burn clinic specialists. But his improvement was slow, which concerned her. ―I offered him the
name of a burn specialist, who was also a plastic surgeon and expert in wound healing, and he opted to seek
treatment from that doctor. He was going to need skin grafting and lots of physical therapy, and working with
this doctor expedited the healing and recovery,‖ said Hamilton.
Hamilton stayed on the case, constantly coordinating the care Riggs received. He had to endure hundreds of
hours of physical therapy, along with multiple surgeries for tissue release and scar revision. Riggs is now back
to work on full duty, three years after that fateful day. His recovery was promising because of the expert care
that was coordinated throughout the whole process.
Aside from the challenges that lie in coordinating care, it is often tough to close a case because of the bond
between the case manager and the patient. ―After spending so much time with these patients, they feel like
family. It‘s hard letting go of that, for them and for me,‖ said Hamilton.
* This is not the patient’s real name.
Hamilton says she occasionally runs into her patients, and it makes her day. ―I recently ran into John one day
as he was dropping off packages, and it was so good to see him back to work. He looked fabulous!‖
Page 26
Catastrophic Challenges
When a catastrophic case comes in, it can be referred by the employer, the insurance company, or the TPA.
Initially, there may only be a little bit of information available. The case manager contacts the hospital to
verify the injury, and if it is deemed catastrophic, they usually want a nurse case manager there right away.
―Generally, when you get to the hospital, the injured person is in the ER, the ICU, or the operating room. One
of the challenges is to build a rapport with the family, and reinforce
to them that I am going to be their point of contact and will do my best to expedite treatment. I also let them
know what case management is, so that they understand what my role is, and I explain all the updates so that
they can be involved in decisions about their loved one,‖ explained Marilyn Compton, a GENEX Catastrophic
Case Manager from Texas. ―If there is an attorney involved in the case, then I need to get permission from him
or her to speak to the family.‖
Compton has been handling catastrophic cases for 28 years, and insists that her background is everything. ―I
spent five years working in a trauma center in radiology, and it was the
best thing for my career,‖ she said. ―It is hard to know what the inside of a body looks like until you see it on a
screen.‖
Upon the patient‘s discharge, Compton is responsible for coordinating the home health care, DME, acute care,
rehabilitation, and visits with multiple doctors. She also needs to make sure the adjuster is completely onboard
with treatments and diagnoses. Compton explained that many times, services need to be pre-authorized and
sometimes they are denied.
Denials can leave the case at a standstill, because they have to go back and figure out what caused the denial.
Sometimes it is as simple as a wrong CPT code or a clerical error; but other
times it could mean that a doctor needs to review it again and approve the service.
―It‘s all a matter of orchestrating so many facets,‖ Compton said. ―You want the best outcome for the patient.
The sad challenge is when the outcome is not going to be what the family and patient are expecting, as can
happen with brain or spinal cord injuries. You have to ready the patient and family for long-term management
of their injuries so that they don‘t fall through the cracks.‖
What are the rewards in her job?
―Everything is so different every day; I can‘t wait to see what it is going to bring me,‖
Compton said. ―I like knowing that I was able to make a difference in someone‘s life; that they can get back to
doing the things in life that they did before. It‘s an amazing feeling!‖
The Role of the Case Manager
Ask Marci Levin about her life as a case manager, and she will tell you that case management is really the 21st
century primary nurse role. ―We have gone from a society that used to have inpatient care for a long period of
time,‖ said Levin. ―Our job depends on a strong knowledge base of nursing, disease orientation, and health.
We need to have education and experience, and nurses at GENEX have it.‖
The shift of treatment has gone from the hospital to outpatient care, and the job of a case manager is a
reflection of what is going on in society. ―Nurse case managers save a lot of money for the employer and the
insurer, because they manage the care correctly,‖ said Levin, who has been handling catastrophic cases for 23
years.
Page 27
A typical day for Levin involves hours of phone calls with doctors, going to doctor visits with patients,
documenting the cases, and visits to the hospital. ―CAT nurses do a little bit of everything; telephonic case
management, field case management, and of course, the catastrophic part.‖
Levin‘s passion for her job is apparent as she explains what she does. ―Sometimes, we are the first people to
speak to the family, and we have to use personal, social, and counseling skills to convey the information to
them, she said. ―Everyone is angry in the beginning, and there is so much to filter and process. They cling to
the case manager for knowledge and strength.‖
Levin said, ―There has to be a calming voice, an advocate for the patient and their family when
they are completely distraught. We are that calming voice for them; we educate them and give them options.
The challenge is to get the patient to move past the anger and on to living
their life and returning to work,‖ said Levin.
Levin said another challenge is working with patients who have pre-existing conditions when they are injured.
―I had one case where the patient was injured on the job, and she was already suffering from end-stage renal
disease. I was shocked that she was even working. That impacts the case even more.‖
The real reward for Levin is seeing someone who has gone through an ordeal, survive, and take back their life,
even if it is a modified-duty job. One of her favorite cases involved a retired accountant who was working as a
security guard in a bank. There was an armed robbery, and the guard had suffered life-threatening gunshot
wounds.
―He was in the ICU and CCU for over a month,‖ said Levin. ―I breathed a sigh of relief once he was moved out
of there and seen as an outpatient for several months. The best part was that the man‘s employer came to see
him frequently and kept in touch with him the entire time he was out of work. They celebrated him, and had a
picture of him on their wall, naming him a hero. He went back to that job in nine months; it was amazing!‖
Levin said that when the employer is 100% involved with their employees‘ recovery, patients have a much
better outcome.
Every Day is a Miracle
―CAT cases are the most rewarding,‖ said Leslie Eldib, Catastrophic Case Manager. ―The joy you feel when
your patients start progressing…it is all a miracle. It helps you understand what is important.‖
Eldib has been handling catastrophic cases since 1991, and has ―done it all‖ clinically. She has been a nurse
since 1974, and has experience in trauma units, the ER, ICU, medical/surgical care, and research studies.
―A lot of times, you want to jump in and fix everything right away, but you have to think about what is best for
the patient long-term. You have to give them time and let them ‗catch up‘ so that they can participate in their
care and make the decisions that will impact the rest of their lives,‖ said Eldib.
When asked what gets her up in the morning, Eldib replied, ―Wonder. What miracles are going to happen
today? How can I make someone else‘s life a little easier?‖
Eldib has experienced many a miracle in her career, but there is one case that tops them all. ―I had a case
involving a 45 year-old man who worked as a lab engineer. One of the machines exploded, and he suffered
severe chemical and thermal burns. The chemicals, arsenic and white phosphorus, were the highest level of
Page 28
chemicals the lab had ever seen,‖ she said. ―The man had almost complete body failure; he lost his left eye and
much of his face, and burns to his upper body.‖
Eldib did not think he was going to make it, and she prepared herself for the worst. Her biggest challenge was
that the family was very private and did not want outside help.
―I could not make contact with the family, and that was very frustrating because I wanted to help them
understand what I was able to do for them,‖ said Eldib. ―They are a very loving and supportive family and did
not realize how much I could assist them.‖ But Eldib was determined, and finally made contact with the family
after three months.
Ensuring that he was placed in a center of excellence as quickly as possible was essential. There he was on a
heart/lung machine and dialysis for a few weeks and in the ICU for four months. He was then discharged from
the ICU and was sent to an inpatient rehabilitation program for a few months.
―As a result of toxic exposure, he became a quadriplegic for six months. Finally, after six months of being in
the hospital, we were able to get him home with supportive services and therapies. His family and team of
providers were thrilled with his progress as he started to regain body function and movement,‖ said Eldib.
Eldib, along with the patient, was facing big challenges ahead, though. Since the patient had experienced a lot
of damage to his face, the next step was to start the process of skin grafting and plastic surgery. It was crucial
that he received rehabilitation at the same time, so they worked out an arrangement where the therapists would
go out to his home for a few months until he was able to get to an outpatient facility.
―There were many modifications that needed to take place in his home so that he could get around. He is still
wheelchair-bound, but can now walk 40 feet with assistance,‖ said Eldib. ―Each day is another miracle for
him!‖
Eldib also stated that there were many specialists involved through which she has to coordinate care, including
an ENT, ophthalmologists, plastic surgeons, burn specialists, wound care specialists, therapists, the primary
care physician, a psychologist, two orthopedists (one for the hands; one for the feet), transportation, home
modification specialists, and 24/7 care. ―You have to constantly be figuring out what is best, because you don‘t
see this level of coordination very often.‖
Eldib is still on the case, and she is continually amazed at his progress. ―He is a very brilliant man, and
thankfully, he retained all of that. His next project is to get speech-recognition soft-ware for his computer so he
can communicate better.
―I attribute a lot of his success to his sense of humor…he just has the best attitude! I am so excited at his
progress, and can‘t wait to see what miracles lie ahead for him in the
future,‖ she said.
GENEX Investing in the Future of Case Management
To underscore just how important case management is for dealing with catastrophic injuries and the company‘s
commitment to providing high quality case management services, GENEX Services, Inc. provides $100,000 in
scholarship awards to schools nominated by GENEX employees that graduated from those institutions. The
scholarships, which are part of GENEX‘s Case Manager Scholarship Award Program, are intended to
recognize the GENEX graduates from the scholarship schools, strengthen the awareness of the case
management profession, and invest in a new generation of future graduates to fill a growing industry need.
Page 29
The schools receiving scholarship awards in 2013 are: Montgomery County Community College, Blue Bell,
PA; Shepherd University, Shepherdstown, WV; University of Alabama at Birmingham, Birmingham, AL;
University of Virginia, Charlottesville, VA; and Western Washington University, Everett, WA.
Each school will receive $20,000 to be used in support of the educational endeavors of their student population
through scholarships.
―It is well known that the demand for nurses has exceeded the available supply of both experienced and new
graduates from nursing programs,‖ said Peter Madeja, CEO of GENEX. ―As the industry leader and employing
1,500 case managers, we are proud that we will create the potential for new students to enter schools and help
address these trends in the future.‖
About the Author: The author of this article is Michele Ritchie. Ritchie is
the Marketing Communications Manager for GENEX Services, Inc. She
has over 16 years working in the communications field. Ritchie spent 14
years working for Aetna in several different positions that included
Communications Manager/Writer, Business Communications Assistant,
National Accounts Project Assistant, Account Manager, Provider Relations
Grievance Analyst, and Marketing Manager. She is the recipient of the
2012 Frank X. Long Award for Excellence in Writing awarded by PRSA
Philadelphia.
Michele Ritchie
This article has been edited to add the section about the GENEX Case
Manager Scholarship Award Program.
About Case Management
For more than a century, case management has meant better coordinated care for patients with complicated
health needs. Over the past two decades case management transitioned from a narrowly applied function to a
fully developed area of practice for professionals to manage the social, medical, financial and behavioral
issues associated with complex cases.
Professional case managers must hold a current, active, and unrestricted licensure or certification in a health
or human services discipline that within its scope of practice allows the professional to conduct an assessment
independently and/or a baccalaureate or graduate degree in social work, nursing, or another health or human
services field that promotes the physical, psychosocial, and/or vocational well-being of the persons being
served.
Today‘s professional case managers are found in health care, workers compensation, behavioral health,
insurance and managed care organizations. Tens of thousands of professional case managers are employed in
a range of health care settings and in independent practice, and, according to the Bureau of Labor Statistics,
case management is one of the fastest growing occupations.
Additional information about Case Managers can be found at the website of the Commission for Case
Manager Certification.
Page 30
Innovation. At Stone Loughlin & Swanson, LLP our passion is administrative law and we have distinguished ourselves
as a "go to" law firm in the areas of health and workers' compensation insurance regulation. Our innovative challenges to
agency action have saved our clients millions of dollars and changed the regulatory landscape for all system participants.
Expertise. We are eight attorneys, a registered nurse, and a dedicated support staff all focused on the same area of
practice, day in and day out. The firm is rated AV by Martindale Hubbell, the nation's leading rating group for lawyers. In
addition, we are the only law firm in Texas chosen to be a member of the National Workers' Compensation Defense
Network.
Presence. We live and work in Austin, home of state regulatory agencies, the State Office of Administrative Hearings
(SOAH), and the Travis County courts (venue for substantial evidence judicial reviews). Our presence in the state capital
allows us to closely monitor agency actions and deliver cost-effective representation in administrative proceedings. In
particular, our proximity to the Texas Department of Insurance, Division of Workers' Compensation makes us perfectly
positioned to assist system participants in the development, certification, and regulation of workers' compensation health
care networks and to assist insurance carriers and self-insured employers with workers' compensation medical necessity
and fee disputes.
P: (512) 343-1300
F: (512) 343-1385
Visit Us Online at: http://www.slsaustin.com/index.html
3508 Far West Blvd., Suite 200
Austin, Texas 78731
Member National Workers’ Compensation Defense Network – A Nationwide Network of Law Firms Practicing in Workers’ Compensation
Page 31
Medication Safety: An Inside Look
Opioid Use is a National Crisis
By Michele Ritchie, Marketing Communications Manager for GENEX
According to the National Council on Compensation
Insurance (NCCI), narcotic prescriptions account for $1.4
billion of workers‘ compensation medication spending
annually. It is such a hot topic with workers‘ compensation
carriers that many states have enacted laws or guidelines to
deal with the issues surrounding opioids. In this issue, we
look at how GENEX Case Managers consider all medications the person is taking, and whether those medications are
helping or hindering the individual‘s recovery process.
Nine Years, 17 Surgeries, 17 Medications
It was 1996. Dan Smith* was working 60-70 hours a week
using air sanders, drills, and other vibrational tools. The
numbness and pain started in both hands and wrists. By 1997, he was feeling the pain in both shoulders and
upper extremities and had already injured his back lifting heavy equipment.
Over the next nine years, Smith had 17 surgeries, including several bilateral carpal tunnel release procedures,
bilateral shoulder arthroscopy, wrist arthroscopy, thumb reconstruction, elbow arthroscopy, and a right elbow
release procedure. At this point, Smith was taking 17 medications, including:
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4 pain medications;
3 depression/anxiety medications;
1 sleep aid medication;
4 reflux medications;
1 blood pressure medication;
3 constipation medications; and
1 nausea/vomiting medication.
By 2011, Smith had undergone several independent medical evaluations, with doctors recommending that no
further surgery be performed, and that he be admitted to a drug rehab program. Heavy opioid use had caused
him to become irrational, which led to despair and depression, which led to medications to combat his
depression. When he wasn‘t happy with one doctor or couldn‘t get medications from them, he would see
another doctor, complaining that his pain was a ―9‖ on a scale of 1-10.
Dan Smith‘s case was complicated, involving second-, third-, and even fourth-opinion doctors. In late 2012,
GENEX became involved, and a Peer-to-Peer Review and Assessment was requested, the results of which
revealed three major issues with Smith‘s case:
● An underlying overuse injury that caused pain to both hands and wrists;
● Significant psychiatric issues, ranging from severe depression to suicidal thoughts, despite
extensive psychotherapy and cognitive behavioral therapy; and
● A clear need for inpatient detox or a similar program that included an outpatient program with a
strong psychological/psychiatric follow-up plan.
Page 32
Based on the review, Smith‘s medications were reduced from 17 down to seven. Smith needed to sign an
opioid treatment agreement, and has to undergo random urine drug monitoring at least twice a year. To put cost
in perspective, monthly savings totaled $3,683; annual savings are $44,206; and $1.4 million is the projected
savings over the claimant‘s expected lifetime. At this time, Smith remains out of work on permanent long-term
disability, due to the injuries in his shoulders and wrists. However, he has significantly reduced his dependency
on opioids.
Medication Safety — Where Do You Start?
In workers‘ compensation, there is a big focus on
opioid abuse, medication misuse, tolerance, and
dependence, as well as physicians prescribing opioids
at the wrong point clinically for the injury. Therefore,
the earlier the case is managed, the better the opportunity to impact the case with a positive result, such as a
return to work and management of pain without
medication.
A GENEX Telephonic Case Manager who receives a new injury case has a window of opportunity to impact
the medication usage issue. However, GENEX Field Case Managers frequently receive cases that are quite old,
and treatment and medication plans, as well as the lack of progress towards recovery, have already been
established. These are the types of cases that are often ―red-flagged,‖ like Dan Smith‘s, because of the
likelihood of opioid abuse.
―Our case managers are required to complete our CCM, CRC, and CDMS-approved Medication Safety Training CEU Program and New Hire Training Module,‖ said Mariellen Blue, RN, CCM, CDMS, National
Director, Case Management Services. ―They know that they cannot impact case outcomes without considering
all medications the person is taking and whether those medications are helping or hindering the individual‘s
recovery.‖
Medication plays a key role in the individual‘s return to wellness — along with surgery, conservative care such
as physical therapy, and the healing properties of time. By recognizing potential issues, GENEX Case Managers
are able to intervene for the safety of the patient.
Using these tools in tandem with medical case
management can substantially decrease the
Medical costs, including the rising costs of
medical spend and improve the patient outcomes,
prescription medications, are increasingly the
especially on cases involving claimants with issues
biggest part of workers‘ compensation claims.
such as chronic pain, catastrophic injuries, and
Case managers are a key part in helping to control other debilitating injuries.
those costs. But GENEX‘s Medication Safety
Program also includes:
Case Managers are often the only educational
GENEX’s Solutions
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Quality Medical Provider Networks
Customized Provider Panels
Utilization Review
Medical Bill Review
Pharmacy Benefit Management
Independent Medical Examinations
Comprehensive Pharmacy Review
resource for the individual, as the provider
frequently does not spend the time on educating.
When a telephonic or field case manager receives a
new case, a complete medication and pain assessment is conducted to determine if the appropriate
diagnostic tests were completed in accordance with
clinical guidelines for the injury. They also need to
Page 33
know if the diagnosis supports the current clinical symptoms and medications. If the diagnosis is incorrect, the
medications prescribed may not lead to recovery for the claimant. Or, worse yet, they could contribute to an
opioid addiction further into treatment.
Part of the assessment includes a discussion with the claimant to determine their treatment plan, to make sure
they fully understand the purpose of the medications, and how to properly take them. The case manager asks
pointed questions regarding the claimant‘s quality of sleep, appetite, perspective, and motivation to return to
work. They spend time with the person and educate him/her about the choices the person makes as they
proceed through the claims and case management process.
GENEX‘s Case Managers are often the only educational resource for the individual, as the provider frequently
does not spend the time on educating and explaining. ―We train our case managers to empower the person by
educating and coaching them,‖ said Blue. ―It is crucial that the claimant knows how to navigate the medical
system and become educated about their injury. They play a vital role in maximizing their own recovery.‖
Educating and coaching the claimant can include such topics as:
●
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Discuss and share drug interaction issues if appropriate
Answer questions about treatment and possible outcomes
Encourage return to productivity and work
Discuss what the person can do on his/her own to manage how they feel and cope
―Our goal is to help the person return as close as possible to their pre-injury/illness state,‖ said Blue. ―Physical
medicine is a big part of that, but so is medication. Education and information can help the individual stay
informed during the process that often leaves many injured people feeling overwhelmed.‖
The claimant must own the process of medication compliance (taking the medication as ordered), reporting on
the medication results to his/her provider, and medication safety (keeping the medication safely out of the hands
of other people), just as the person owns the process of complying with treatment like physical therapy.
About the Author: The author of this article is Michele Ritchie. Ritchie is the Marketing Communications
Manager for GENEX Services, Inc. She has over 16 years working in the communications field. Ritchie spent
14 years working for Aetna in several different positions that included Communications Manager/Writer,
Business Communications Assistant, National Accounts Project Assistant, Account Manager, Provider
Relations Grievance Analyst, and Marketing Manager. She is the recipient of the 2012 Frank X. Long Award
for Excellence in Writing awarded by PRSA Philadelphia.
This article has been republished with the permission of GENEX Services, Inc
The GENEX corporate mission is to provide exceptional healthcare and disability management solutions to
their customers, to be a strategically important business partner, and through their competitive spirit and
unsurpassed delivery of innovative services, to create a brighter future for those they serve.
There simply is NO other Daily News Outlet that
provides you with timely coverage of developments
impacting the Texas workers‘ compensation system.
Page 34
Medicare Secondary Payer Statute Does Not Preempt Texas’ Preauthorization Law
By Randy McNeel, Marketing Director, Thornton Law Firm
The United States Fifth Circuit of Appeals Court recently ruled that the Medicare Secondary Payer Statute
(MSP) does not preempt the Texas statute requiring preauthorization for certain procedures1.
Guadalupe Caldera (Caldera) injured his back on-the-job in 1995. The carrier for his employer, Insurance
Company of the State of Pennsylvania (ICSP), paid Caldera the statutory benefits owed. In 1998, he applied for
and was granted Medicare benefits.
Medicare paid for the subsequent two surgeries in 2005 and 2006. Caldera had not sought preauthorization from
ICSP, but filed a claim alleging ICSP was liable for the payments not Medicare.
ICSP and Caldera went through the extent of injury dispute process, and when Caldera exhausted his
administrative remedies, he filed for judicial review. The matter was settled with an Agreed Judgment that
established Caldera‘s 1995 injury was the producing cause of both surgeries but did not settle any damages or
require any payment by ICSP.
Caldera filed a MSP reimbursement claim against ICSP, but it relied on the failure of Caldera to obtain the
required preauthorization for his surgeries. He argued that ICSP ―can reasonably be expected‖ to pay because
MSP preempts the Texas preauthorization provisions.
Caldera filed for a declaratory judgment in the U. S. District Court for the Southern District of Texas that was
dismissed for failure to exhaust his administrative remedies. On appeal, Caldera continued to argue the MSP
preempted the Texas preauthorization provisions. In the majority opinion, the court agreed that workers‘
compensation insurers are prohibited from subordinating their payment obligations to Medicare, but MSP does
not go so far as to eviscerate the Texas statute.
The court found there was no conflict in allowing Medicare and the Texas workers‘ compensation act from
reaching opposite conclusions about Caldera‘s need for surgery.
The court noted that Caldera did not even seek preauthorization from the Division of Workers‘ Compensation
which deprived it of any opportunity to determine if the surgeries were related to his two back injuries.
The court noted that under the MSP, if a claimant fails to file a proper claim in accordance with state law
requirements, and therefore, cannot recover benefits from the primary payer, ―so be it‖. Medicare can refuse to
make a conditional payment, or it can seek reimbursement from the claimant himself. In any event, the claimant
cannot succeed under the MSP.
The Fifth Court found that Caldera failed to state a claim and affirmed the district court‘s ruling.
Editor’s Note: This article was written by Randy McNeel. McNeel was the marketing director of Thornton,
Biechlin, Segrato, Reynolds & Guerra (Thornton Law Firm). Randy worked for the Harris & Harris law firm
prior to his employment at the Thornton Law Firm. Prior to his employment with the two law firms, he worked
for Aetna Insurance Company and Cigna Insurance Company. Randy was highly thought of by all who had the
honor of knowing and working with him. Randy passed away on Tuesday, June 4, 2013 as the result of acute
myeloid leukemia. An In Memoriam follows.
1
See Texas Labor Code §413.014 and 28 Texas Administrative Code §134.600.
Page 35
In Memoriam – Randall M. McNeel, Jr.
September 14, 1945 – June 4, 2013
Randall M. ―Randy‖ McNeel, Jr., a highly respected and well
regarded workers‘ compensation insurance expert and friend of many
insurance and other professionals within the Texas workers‘
compensation system, passed away at the age of 67 on June 4, 2013
as the result of acute myeloid leukemia. Randy is survived by his
wife of 46 years, Cynthia, his sister and brother in law Marilyn
McNeel Lee and W.C. ―Bud‖ Lee, Jr. of Hardin, Texas. He is also
survived by his nephew and great niece. Randy is additionally
survived by all whose lives he touched and impacted.
Remembrances
Stuart Colburn, Shareholder and
Attorney with Downs Stanford, P.C.
Professionally, Randy was an insurance
expert and an effective manager.
Personally, Randy was an invaluable
mentor and friend. My wife and I are
saddened by his loss and express our
sympathies to his family, especially to
his incredible wife Cindy.
Brandi Prejean, Associate, Thornton
Law Firm
For 11 years, Randy was a generous
mentor and friend to me. He enjoyed
being at the forefront of changes in the
workers' compensation system and
possessed an infectious enthusiasm
regarding anything affecting the
insurance industry. Randy was always
willing to share his vast knowledge and
experience and never tired of offering
his assistance. Whatever the task, Randy
was dedicated to do the job right
combined with a humor that often made
work, not feel like work. He was a
significant influence in my career and
I will forever be grateful for the
opportunity to have worked with him,
learned from him, and laughed with
him.
A Guest Book for Randy can be
found here.
Randy graduated from Sam Houston State University in 1968 with a
Bachelor of Business Arts degree. He was recruited by Aetna
Insurance Company (Aetna) of Hartford, Connecticut out of college
and began his career in the insurance management and claims
administration after graduating from college. Randy progressed
through the ranks at Aetna and later at Cigna Insurance Company
(Cigna). He served as the claims manager for Cigna in their Dallas,
Texas office.
For recreation, Randy enjoyed running and playing golf with his
wife, Cindy. Randy often said that Cindy was the best part of him
and credited her for his impeccable grammar and improved golf
game.
Randy worked for the Harris & Harris law firm and the law firm of
Thornton, Biechlin, Segrato, Reynolds & Guerra (Thornton Law
Firm) after leaving Cigna. At the time of his passing, Randy was the
Thornton Law Firm‘s marketing director.
Randy was active in the workers‘ compensation legislative and
regulatory processes in Texas. He was highly regarded and sought
out for his knowledge about the workers‘ compensation system in
Texas.
During his career with the two law firms, Randy was instrumental in
the law careers of several attorneys who all say he taught them about
the complexities of workers‘ compensation in Texas and was a good
friend to them.
A memorial service was held for Randy at the First Baptist Church of
Austin, Texas on Saturday, June 8, 2013. A donation in honor of
Randy may be made to the First Baptist Church‘s general fund.
Randy‘s legacy shall live on through his hard work and the careers of
those he helped shape. His wise counsel on workers‘ compensation
and other issues along with his great wit will be missed.
Page 36
Payers, Providers Optimistic About Specialty Networks Bill
By John P. Kamin, WorkCompCentral Reporter
Providers and payers are optimistic that a new bill allowing home health care services and durable medical
equipment providers to voluntarily create informal "specialty" networks in the state workers' compensation
system will create more economic opportunity and provide more services to rural areas.
Texas state Sen. Leticia Van de Putte, D-San Antonio, had little trouble moving Senate Bill 1322 through the
state Legislature during the legislative session that ended on Monday. The bill passed the Senate with
a 30-0 vote and won House approval with a 145-3 vote. The bill is now on Gov. Rick Perry's desk 2 for his veto
or final approval.
Senate Bill 1322 would revise a Texas law that prohibits home health care and DME providers from creating
their own voluntary and informal networks.
John Greeley, spokesman for the Division of Workers' Compensation, said that has been the state of law since
2007, when Texas lawmakers approved House Bill 473, by Rep. Burt Solomons, R-Carrollton. The bill
required all informal and voluntary health care networks to become "certified networks," which are subject to a
number of regulatory requirements.
Since then, lawmakers amended the law in 2011 and allowed pharmacies to create informal and voluntary
networks, he said. These informal and voluntary networks are more commonly known as "specialty networks."
Trey Gillespie, senior workers' compensation director of the Property Casualty Insurers Association of
America, said that legal requirements made it too costly for home health care and DME providers to form
"certified networks."
"You had to have a full list of providers who provide all sorts of services, not just a specialized service," he
said of the requirements for certified networks.
Faced with the burdensome requirements, home health care and DME providers saw little sense in the creation
of a large certified network just to offer discounts on home health care and DME specialties, Gillespie said.
"These types of informal networks should not have to go through the extensive regulation of becoming a
certified network -- with the requirements of having health care providers in a broad spectrum of fields
and contracts with hospitals -- just so they can give price discounts to insurers and employers on durable
medical equipment and home health care services," he said. "So this (bill) is a good exception to the
prohibition."
Albert Betts, general counsel for the Insurance Council of Texas and attorney for the Thompson Coe law firm,
said that he lobbied for the bill on behalf of providers. Betts is also the former commissioner of the DWC.
"Providers of DME and home health services wanted the opportunity to be able to contract at discounted rates
outside of a (certified) network, in order to increase their business competition," he said. "Payers ultimately
supported the bill during legislative hearings. This is provider-driven."
2
Editor‘s Note: Senate Bill 1322 was signed by Gov. Rick Perry on June 14, 2013 and will become effective September
1, 2013.
Page 37
While SB 1322 affects home care and DME providers, Betts anticipates that payers will see the most savings
from DME specialty networks. He noted that DME costs currently account for $35 million a year in the Texas
workers' compensation system.
"According to DWC data, 10% of all injured employees receive one or more DME services and DME accounts
for roughly 10% of all medical costs," Betts said. "These figures do not include hospital DME costs."
Brian Allen, vice president of government affairs for Progressive Medical, said the bill will allow home health
care and DME networks to contract with certified networks and payers directly. He said that allowing the two
types of providers to form specialty networks offers providers much more than the promise of increased
business volume, in exchange for the discounted rates.
"The benefits on the providers' side really are that you have got someone who is at a central billing point, so
they are not being billed from multiple billing locations," Allen said. "They can automate a lot of that
billing and approval process, so they are not having to do these billings with each individual carrier. They can
use a specialized network solution to do that."
Additionally, the specialty network model offers opportunities to smaller vendors, who might be overlooked by
some of the large health care networks, he said. Informal specialty networks can also provide services to
underserved, rural areas, Allen said.
"One of the things these specialty networks can do is they can get into underserved networks better, because
they are not necessarily looking for huge volume," he said. "A lot of Texas is rural, so the opportunity for some
of the rural providers to get hooked into a network and take advantage of that is there."
While many networks cover the entire state, they tend to have regional subsections, Allen said. This allows
payers to choose who in the specialty network will serve their injured workers.
"If you have a small self-insured employer that fits into one region, then all of those providers will be
regional," he said. "If you have a larger employer that covers the entire state, then we would use regional
providers to service groups of employees in various regions."
This approach allows rural providers to continue working with businesses that they are already serving, while
welcoming new opportunities, Allen said.
While the bill passed through the Legislature with relative ease and will become law on Sept. 1 if Perry signs
the bill, the DWC would still need time to promulgate regulations to oversee the networks.
Allen said that he is confident that the division will efficiently create the new regulations, which he said should
be similar to the regulations for pharmacy benefit networks. Companies such as Progressive Medical will not
begin forming home health care and DME specialty networks until the regulations are finalized, he said.
Allen said that the amount that providers are willing to discount will vary from contract to contract and will
depend on the stances of each individual provider and employer. That being said, Allen anticipates that
the discounted rates will be lower than the Medical Fee Schedule.
While payers in other states have struggled with skyrocketing home care and DME costs in recent years, Betts
said that Texas' fee schedule has kept DME and home care services under control for more than a decade.
Page 38
John Kamin
Editor’s Note: This article was written by John P. Kamin, a WorkCompCentral
reporter, and was originally published on May 31, 2013. The article has been
republished with the permission of WorkCompcentral. Kamin is a reporter for
WorkCompCentral, where he has covered workers' compensation issues since
2007. Kamin received a juris doctorate from the Ventura College of Law in 2012,
and has worked as a professional journalist since graduating from the University
of Arizona with a journalism degree in 2002. Prior to covering workers'
compensation issues, Kamin worked for several newspapers in rural Arizona,
where he specialized in developing online media while covering legal,
entertainment, and real estate issues. He currently resides in Oxnard, California.
WorkCompCentral is the top source of daily news on developments impacting Texas workers’ compensation
systems around the nation. Additional information about WorkCompCentral can be found here.
Believers in Texas Opt-Out Model Fear Oklahoma-Type Mandate
By John P. Kamin, WorkCompCentral Reporter
Many Texas employers that opt out of the state's voluntary workers' compensation system purchase alternative
benefit plans to cover workplace injuries, but that doesn't mean they want a state mandate forcing them to.
A bill signed into law by Oklahoma Gov. Mary Fallin on May 6, 2013 that allows employers to opt out of
workers' comp if they provide equivalent benefits through an alternative plan has some employers worried that
Texas lawmakers will consider similar rules.
Some Texas nonsubscribers are concerned their state might take a cue from Oklahoma, said Diana Craft,
president and chief executive officer of Providence Risk & Insurance Services in an interview with
WorkCompCentral. ―Certainly we‘ve all thought, ‗how is that going to impact Texas?‘‖ said Craft, who has
been administer-ing claims for Texas nonsubscribers since she founded the company in 1996. ―It has crossed
our minds, with Oklahoma moving to require specific limits and a duration period equal to workers‘
compensation.‖
The Texas Association of Responsible Nonsubscribers estimates that more than 100,000 Texas businesses
currently operate as nonsubscribers. They represent all types of businesses and range in size from a few
employees to Fortune 500 companies with multi-state operations. Many of the Texas nonsubscribers provide
alternative workplace injury benefit programs.
―I personally do not want the nonsubscriber market regulated more than it is already regulated. We have very
strict rules that we follow with regard to benefit determinations and timelines that is controlled by the
Department of Labor for an ERISA (Employee Retirement Income Security Act) plan. When you have too
many hands in the pot, it muddies up the water,‖ she said.
Chance Fleming, a Texas-based claims manager for Sedgwick, said any move in Texas to mandate an
alternative plan would scare a lot of employers, especially small employers. "They are some that are probably
concerned. There are a lot of small companies here in Texas that just don‘t have the money to provide benefits.
I think (mandating an alternative plan) will scare them," said
Fleming.
While the thought of such a mandate has been discussed, there is no indication Texas lawmakers are preparing
to introduce any such mandates on nonsubscribers. Craft believes that is not likely to happen.
Page 39
―Texas has some very strong leaders both in the legislature and within the business community who believe
what we have is working and working well. The satisfaction rate from the employees is very high,‖ she said.
William Minick, president of PartnerSource, said the time to mandate benefit coverages for nonsubscribers in
Texas has long since passed. ―In the early 1990s, when there was absolutely no best practices for claims
handling and an embryonic insurance marketplace, there was great opportunity for abuse and employees to be
left without coverage. Today, the Texas nonsubscriber market is very mature, there are many carriers writing
this coverage, at virtually any deductible and coverage limit, it‘s a very competitive marketplace, and the vast
majority of employees in this environment have adequate benefits coverage,‖ said Minnick.
Minick said is simply no need now for mandated government involvement in starting a new program in
Oklahoma or another state. He also argued that a mandate would be expensive for tens of thousands of nonsubscribing employers because they would ―have to completely revise and roll out all their program
documentation, and have all the third-party administrators and insurance carriers making changes to their
systems and practices."
Indeed, the Texas Association of Responsible Nonsubscribers has been lobbying for Texas businesses to retain
the right to operate as nonsubscribers, a freedom the group likes to point out doesn't exist in most states and
which it attributes to its campaign over nearly two decades.
Craft said while the Texas nonsubscribers generally believe in the opt-out model, not all of those with operations
in Oklahoma are going to drop out of the traditional workers‘ compensation system. ―Oklahoma would be much
more regulated by the state as well as the Department of Labor because it is a benefit plan that meets the
definition of an ERISA plan. I think that would be a bigger challenge for some employers because it is requiring
they provide the same benefit limits and same duration or lifetime medical coverage,‖ she said.
Craft said some of her clients with Oklahoma exposure are waiting for the new law to go through an expected
legal challenge before they make a decision on what to do next. ―They are certainly going to wait until we‘ve
gotten through any legal activity with regard to the law. We are having regular meetings to identify and
develop processes so that we‘re ready when any of our clients
make the decision to flip the switch in Oklahoma.‖
Editor’s Note: This article was written by John P. Kamin, a WorkCompCentral reporter, and was originally
published on May 22, 2013. The article has been republished with the permission of WorkCompcentral.
Kamin is a reporter for WorkCompCentral, where he has covered workers' compensation issues since 2007.
WorkCompCentral is the top source of daily news on developments impacting Texas workers’ compensation
systems around the nation. Additional information about WorkCompCentral can be found here.
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Page 40
Page 41
Column: DePaolo's Work Comp World
Texas Case Highlights Importance of Comp
By David DePaolo, CEO, President, Editor-in-Chief, WorkCompCentral
The common theory in Texas, and maybe Oklahoma soon, is that the employer has an advantage when a
nonsubscriber using benefit plans and arbitration to govern dispute resolution.
But that‘s not entirely true and an employer will be paying damages, perhaps significant damages, if the trier of
fact, even an arbitrator, finds that the employer has a responsibility to an employee for work injuries.
Ricky Guzman, a machine operator for Forged Components, was hit by a forklift by a coworker who
accidentally backed into him, crushing Guzman‘s lower left leg. Emergency personnel flew Guzman to a
Houston hospital, where he stayed for 27 days as doctors performed a fasciotomy and grafting to repair
Guzman‘s leg.
Forged quickly obtained a urine sample while Guzman was in the hospital, which tested positive for marijuana
and cocaine. The employer raised an intoxication defense and denied medical benefits.
Guzman filed a negligence suit against the nonsubscribing employer, and Forged Components filed a motion to
compel the case into arbitration, citing its benefit plan. The trial court denied the motion to compel.
One week later, the parties agreed to arbitrate the claim anyway and decided to formalize the agreement under
Rule 11 of the Texas Rules of Civil Procedure. Forged‘s attorney sent Guzman‘s attorney a ―Rule 11‖ letter
stating that they had agreed to submit the matter to Judge Katie Kennedy of Judicial Workplace Arbitrations.
The letter agreement was signed and returned to Forged‘s attorney, but despite creating the letter, Forged never
signed the Rule 11 agreement.
Months later, Kennedy awarded Guzman $1.3 million, after determining that the plaintiff was not intoxicated
at the time of his injury because the presence of THC metabolites does not establish intoxication at the time of
injury and there was no evidence to indicate such.
Forged didn‘t like the outcome of the arbitration, so it filed a motion asking the 55th District Court of Harris
County to vacate the award. The court denied the motion and awarded Guzman interest on the award.
Forged appealed, and on Tuesday, the 1st District Court of Appeals affirmed the $1.3 million award but denied
Guzman interest on the award.
Forged contended that the Rule 11 agreement was unenforceable because the Texas Arbitration Act requires
both parties to sign an arbitration agreement, and Forged had never signed the agreement.
The appellate court determined that the Federal Arbitration Act did apply, however, which did not require both
parties to sign the Rule 11 agreement, and deemed it enforceable.
Forged also argued, in what I would characterize as a desperate attempt to avoid the award, that the trial court
should have granted its original motion to compel arbitration under its nonsubscriber plan, rather than the
arbitration under the Rule 11 agreement.
Page 42
The appellate court said that there was no difference between the two and that both arbitration proceedings
were essentially the same.
In Texas, you either have workers‘ compensation insurance, or you don‘t. If you don‘t, then you have to face
liability as determined by civil law.
And this is what makes Texas such a great state in modern times because it serves as a reminder to all of the
employers out there that complain about workers‘ compensation – just look at the alternative...
Workers‘ compensation schemes are nothing more than a mechanism for allocation of risk. We may tweak
how that risk is determined, or what the size of that risk is, or whether one employer‘s operation constitutes a
greater risk than another – but at the end of the day it‘s all about sharing the burden.
What makes modern economies hum is that humans are social in nature. We all need each other and
collectively we create an order that is much bigger than the sum of its individual parts.
Everyone shares the risk of building an economy – the support system that enables mankind to live longer,
fuller lives and advance the species to new levels of function and prosperity.
As a consequence, everyone also shares in the rewards – no single employer is, theoretically, burdened by a
single catastrophic event that would put people, who otherwise may have nothing to do with the catastrophe,
out of work.
I had lunch with an industry friend the other day – someone that has been in workers‘ compensation even
longer than me and someone that is, in my opinion, much more intelligent than me.
My friend offered, between bites of his tri-tip sandwich, that he felt that workers‘ compensation was truly an
important piece to modern, progressive economies and that without this mechanism of sharing the risk (and
reward) business would be much less predictable, and much more volatile – ergo the economy would also
share those same characteristics.
I tend to believe that is a truism – workers‘ compensation is a small industry in the grand scheme of things, but
is essential to successful, global economies. The form, shape, operative rules, etc. may differ from one
economy to another, but in the end it is this obligation to the social order that provides economic vitality.
The Texas case above is out of the 1st District Court of Appeals, titled Forged Components v. Ricky Guzman,
NO. 01-11-00563-CV (06-25-2013).
Other Articles of Interest from DePaolo’s Work Comp World
TX Innovates With Specialty Networks
May 31, 2013
Article
Workers‘ Compensation Finance 101
May 21, 2013
Article
It‘s Not Rocket Science, But Close
May 20, 2013
Article
Survey Shows Work Comp Foreign to Immigrants
March 27, 2013
Article
Page 43
New AMA Classification of Obesity: How It Affects Workers’ Comp And Mandatory Reporting
By MaryRose Reaston, Founder of Emerge Diagnostics
On June 16, 2013, the American Medical Association voted to declare
obesity a disease rather than a comorbidity factor. This change in
classification will affect 78 million American Adults and 12 million
children. The new status for obesity means that this is now considered a
medical condition that requires treatment. In fact, a recent Duke
University / RTI International / Centers for Disease Control and
Prevention study estimates 42 percent of U.S. adults will become obese
by 2030.
According to the Medical Dictionary, obesity has been defined as a
weight at least 20% above the weight corresponding to the lowest death
rate for individuals of a specific height, gender, and age (ideal weight).
Twenty to forty percent over ideal weight is considered mildly obese; 40-100% over ideal weight is considered
moderately obese; and 100% over ideal weight is considered severely, or morbidly, obese. More recent
guidelines for obesity use a measurement called BMI (body mass index) which is the individual‘s weight divided
by their height squared times 703. BMI over 30 is considered obese.
The World Health Organization further classifies BMIs of 30.00 or higher into one of three classes of obesity:
● Obese class I = 30.00 to 34.99;
● Obese class II = 35.00 to 39.99; and
● Obese class III = 40.00 or higher.
People in obese class III are considered morbidly obese. According to a 2012 Gallup Poll, 3.6% of Americans
were morbidly obese in 2012.
The decision to reclassify obesity gives doctors a greater obligation to discuss with patients their weight
problem and how it‘s affecting their health while enabling them to get reimbursed to do so.
According to the Duke University study, obesity increases the healing times of fractures, strains and sprains,
and complicates surgery. According to another Duke University study that looked at the records for workrelated injuries:
● Obese workers filed twice as many comp claims.
● Obese workers had seven times higher medical costs.
● Obese workers lost 13 times more days of work.
● Body parts most prone to injury for obese individuals included lower extremities, wrists or hands, and
the back. Most common injuries were slips and falls, and lifting.
The U.S. Department of Health and Human Services said the costs to U.S. businesses related to obesity exceed
$13 billion each year.
Page 44
Furthermore, a 2011 Gallup survey found that obese employees account for a disproportionately high number
of missed workdays. Also earlier National Council on Compensation Insurance (NCCI) research of workers‘
compensation claims found that claimants with a comorbidity code indicating obesity experience medical costs
that are a multiple of what is observed for comparable non-obese claimants. The NCCI study demonstrated that
claimants with a comorbidity factor indicating obesity had five times longer indemnity duration than claimants
that were not identified as obese.
Prior to June 16, 2013, the ICD code for comorbidity factors for obesity in workers‘ was ICD-9 code 278. This
is related to obesity-related medical complications, as opposed to the condition of obesity. Now the new ICD
codes will indicate a disease, or condition of obesity which needs to be medically addressed. How will this
affect work-related injuries?
Instead of obesity being a comorbidity issue, it can now become a secondary claim. If injured workers gain
weight due to medications they are placed on as a result of their work-related injury or if an injured worker
gains weight since they cannot exercise or keep fit because of their work-related injury and their BMI exceeds
30, they are considered obese and are eligible for medical industrially related treatment. In fact, the American
Disability Act Amendment of 2008 allows for a broader scope of protection and the classification of obesity as
a disease means that an employer needs to be cognizant that if someone has been treated for this disease for
over 6 months then they would be considered protected under the American Disability Act Amendment.
Consider yet another factor: with the advent of Mandatory Reporting (January 1, 2011) by CMS that is
triggered by the diagnosis (diagnosis code), the new medical condition of obesity will further make the
responsible party liable for this condition and all related conditions for work-related injuries and General
Liability claims with no statute of limitations. It is vital to understand that, as of January 1, 2011, Medicare has
mandated all work-related and general liability injuries be reported to CMS in an electronic format. This means
that CMS has the mechanism to look back and identify work comp related medical care payments made by
Medicare. This is a retroactive statute and ultimately, it will be the employer and/or insurance carrier that will
be held accountable.
The carrier or employer could pay the future medical cost twice — once to the claimant at settlement and later
when Medicare seeks reimbursement of the medical care they paid on behalf of the claimant. This is outside
the MSA criteria. The cost of this plus the impact of the workers‘ compensation costs as well as ADAA issues
for reclassification of obesity for an employer and carrier are incalculable.
The solution is baseline testing so that only claims that arise out of the course and scope of employment
(AOECOE) are accepted. If a work-related claim is not AOECOE and can be proved by objective medical
evidence such as a pre- and post-assessment and there is no change from the baseline, then not only is there no
workers‘ compensation claim, there is no OSHA-recordable claim, and no mandatory reporting issue.
A proven example of a baseline test for musculoskeletal disorders (MSD) cases is the EFA-STM program.
EFA-STM Program begins by providing baseline injury testing for existing employees and new hires. The data
is only interpreted when and if there is a soft tissue claim. After a claim, the injured worker is required to
undergo the post-loss testing. The subsequent comparison objectively demonstrates whether or not an acute
injury exists. If there is a change from the baseline site specific treatment, recommendations are made for the
AOECOE condition ensuring that the injured worker receives the best care possible.
Baseline programs such as the EFA-STM ensure that the employee and employer are protected and take the
sting out of the new classification by the AMA for obesity.
Page 45
Key Takeaways from New AMA Classification of Obesity
On June 16, 2013, the American Medical Association voted to declare obesity a disease rather than a
comorbidity factor. The new status for obesity means that this is now considered a medical condition that
requires treatment.
A recent Duke University / RTI International / Centers for Disease Control and Prevention study estimates
42 percent of U.S. adults will become obese by 2030.
The decision to reclassify obesity gives doctors a greater obligation to discuss with patients their weight
problem and how it‘s affecting their health while enabling them to get reimbursed to do so.
The American Disability Act Amendment of 2008 allows for a broader scope of protection and the
classification of obesity as a disease means that an employer needs to be cognizant that if someone has
been treated for this disease for over 6 months then they would be considered protected under the
American Disability Act Amendment.
With the advent of Mandatory Reporting (January 1, 2011) by CMS that is triggered by the diagnosis
(diagnosis code), the new medical condition of obesity will further make the responsible party liable for
this condition and all related conditions for work-related injuries and General Liability claims with no
statute of limitations.
Editor’s Note: The author of this article is MaryRose Reaston. Reaston is the
Founder of Emerge Diagnostics, an Oklahoma-based company created to
commercialize the Electrodiagnostic Functional Assessment (EFA). Emerge
Diagnostics focuses on reducing their clients’ claims costs via early
resolution and enhanced treatment options for soft tissue injuries. They are
experts in the field of electrodiagnostic medicine as it applies to injuries in
the workplace and leaders in the ongoing development of innovative
technology.
The article was originally published on the website of Insurance Thought
Leadership. The opinions expressed in the article are those of the author and
should not be misconstrued as the opinion or position of the Insurance
Council of Texas.
Other Articles of Interest Presented by Insurance Thought Leadership
What Do New Workers‘ Compensation Reforms Sweeping the Country Have in Common?
Article
What An Employer Can Do To Reduce Soft Tissue Injuries In The Transportation Industry
Article
Repetitive Stress Injury Has Become Cumulative Trauma for Employers
Article
Immigration Reform On The Horizon: What It Means For Medical Tourism And
Workers‘ Compensation
Article
Page 46
Page 47
New Accident Prevention Rules Adopted by Commissioner of Workers’ Compensation
On March 18, 2013, the Texas Department of Insurance‘s (TDI) Division of Workers‘ Compensation (DWC)
announced that Commissioner of Workers‘ Compensation Rod Bordelon has adopted new Accident Prevention
Services – 28 Texas Administrative Code (TAC) §166.2, amended §§166.1, 166.3, and 166.5, and repealed
§§166.2, 166.4, and 166.6 – 166.9.
The rules update various notice, service, and reporting requirements imposed upon insurance companies
regarding accident prevention services associated with Chapter 411, Subchapter E of the Texas Labor Code.
The adopted rules are effective October 1, 2013 and can be found on the DWC‘s website.
Commissioner Bordelon has repealed the current rules effective October 1, 2013.
Commissioner Bordelon and DWC staff worked with the insurance industry and other system stakeholders on
the amendment of the accident prevention services rules. The DWC published three informal drafts of the new
and amended sections on the TDI website on June 8, 2012, August 17, 2012, and November 1, 2012, and
received several informal comments. As a result of some of the informal comments received and other
feedback from system participants, the DWC made several changes to the proposed rule.
Additionally, DWC staff and Commissioner Bordelon met with stakeholders to discuss specific issues of
concern that the insurance industry had about the informal draft rules. A public hearing for the proposed rules
was held on January 4, 2013.
The DWC Form-105, Accident Prevention Services Worksheet, and DWC Form-109, Accident Prevention
Services Annual Report, have been revised to conform to the adopted rules. The forms will be available for
download on or before October 1, 2013 from the DWC website.
TDI Says All Health Care Providers Who Conduct Utilization Review Must Be Licensed in Texas
The Texas Department of Insurance (TDI) has taken a position that all health care providers who conduct
utilization review on Texas workers‘ compensation claims must hold an unrestricted license, administrative
license, or to be otherwise authorized to provide health care by a licensing agency in the United States, or in
Texas, respectively. See TDI Rule 19.2006(a) and Page 36 of the rule adoption preamble.
The requirement for a Texas license was discussed by TDI‘s Utilization Review Advisory Committee (URAC)
during several of the committee‘s meetings. The URAC recommended to TDI that all health care providers
conducting utilization review, to include nurses, be required to be licensed in Texas. TDI accepted the
recommendation.
During the course of the public comment period, several commenters raised the issue of licensing of nurses and
non-health care provider staff and sought clarification. The commenters argued that nurses should not have to
be licensed in Texas since they are performing utilization review under the direction of a physician licensed in
Texas. TDI declined to make the requested change prior to adopting the new rules.
TDI has reported that several URAs have listed health care providers who are not licensed in Texas as health
care providers who are performing utilization review in Texas. TDI is in the process of informing the URAs
that the URA may not utilize the services of health care providers who are not licensed in Texas.
Page 48
For the last sixty years, Flahive, Ogden & Latson has
defended workers‘ compensation claims before three
state agencies and state courts at every level. Our
practice is limited to workers‘ compensation defense
throughout the State of Texas. Twenty-one lawyers in
the firm have been designated as board certified
specialists in workers‘ compensation law by the
Texas Board of Legal Specialization.
504 Lavaca Suite 1000 P.O. Box Drawer, 13367
Capitol Station Austin, Texas 78711
Tel 512.477.4405 | Fax 512.867.1700
Email [email protected]
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Flahive Ogden & Latson Texas Workers‘
Compensation Manual
Our insurance carrier clients include six of the largest
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third party administrators, three self-insured groups,
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self-insureds.
Among the lawyers in the firm, one is a former
Justice on the Court of Appeals and one is a former
Contested Case Hearing Officer for the Texas
Workers‘ Compensation Commission. Four of the
firm‘s lawyers were honors graduates, three were
editors of their respective law school Law Reviews,
four were selected by the Texas Court of Appeals to
prestigious judicial clerkships, and one served as a
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Visit FOL online at www.fol.com.
Page 49
TDI Issues Data Call for Closed Formulary Legacy Claims
On July 1, 2013, the Texas Department of Insurance‘s (TDI) Workers‘ Compensation Research and Evaluation
Group (WCREG) issued a data call for the purpose of collecting information on legacy claims that have been
prescribed and dispensed at least one of the drugs excluded from the Division of Workers‘ Compensation‘s
(DWC) adopted pharmacy closed formulary, e.g., N-Drugs. The requested data had to be submitted to the
WCREG by close of business on July 31, 2013. Incomplete or inaccurate data not corrected and resubmitted by
the due date will be considered late.
Effective September 1, 2013, legacy claims fall under new rules that require preauthorization for all N-drug
prescriptions unless an agreement is reached between the insurance carrier and the prescribing doctor on a
claim-by-claim basis.
In preparation for the new rules, the WCREG has requested that the selected insurance carriers submit to TDI
current information on all legacy claims, those submitted in the March data call, as well as any additional
legacy claims not reported previously. Claims with no changes after the March 2013 data call must still be
reported.
The requested data elements were the same as the March 2013 data call. Insurance carriers must submit the
requested information on all legacy claims with injury dates prior to September 1, 2011 with at least one drug
excluded from the Division of Workers‘ Compensation‘s pharmacy closed formulary (i.e., N-Drugs) dispensed
between September 1, 2012 and July 15, 2013.
The following insurance carriers were subject to the data call:
Ace American Insurance Compny
Old Republic Insurance Company
American Home Assurance Company
Safeco Insurance Company of America
Amguard Insurance Company
State Office of Risk Management
Arrowood Indemnity Company
Texas A & M University System
Big Spring ISD
Texas Cotton Ginners Trust
City of Austin
Texas Department of Transportation
Facility Insurance Corporation
Texas Mutual Insurance Company
Harris County
Texas Property & Casualty Insurance Guaranty Assn.
Hartford Fire Insurance Company
Travelers Indemnity Company
Hartford Ins Co of the Midwest
Travis County
Indemnity Insurance Company of North
America
Insurance Company of the State of PA
Texas Municipal League Intergovermental Risk Pool
Liberty Insurance Corporation
University of Texas System
Liberty Mutual Fire Insurance Company
Zurich American Insurance Company
United States Fidelity & Guaranty Company
New Hampshire Insurance Company
Page 50
―The DWC is particularly interested in the number of peer-to-peer conversations and agreements reached
between insurance carriers and prescribing doctors,‖ DC Campbell, Director of TDI‘s Workers‘ Compensation Research and Evaluation Group. ―Results from the March data call show that for insurance carriers
who conducted peer-to-peer conversations with prescribing doctors, approximately 70 percent of these
conversations ended with agreements on individual legacy claims.‖
Campbell noted that ―the WCREG may subsequently ask for validation of any data submitted so please take
steps to ensure that any data submitted is complete and accurate.‖ He also noted that one additional data call
will be made in the future.
―The WCREG will issue a final data call after the September 1, 2013 deadline to obtain complete information
on the status of legacy claims subject to the pharmacy closed formulary,‖ said Campbell. ―The results of this
data call will also be published by insurance carrier on TDI‘s website.‖
Updated Report on Impact of the Texas Pharmacy Closed Formulary Released by TDI
On July 9, 2013, the Texas Department of Insurance‘s (TDI) Workers‘ Compensation Research and Evaluation
Group (WCREG) released an update to the report on the impact of the Texas Pharmacy Closed Formulary on
prescription drugs prescribing and utilization. The report can be found here.
The report is based on 12 months of injuries, each calculated at nine months maturity. The previous report was
based on six months injuries and nine months of services. The comparison years are 2009 and 2010 (preformulary) and 2011 (post-formulary).
―All indications are that the decreases in N-drug utilization seen in the first three months and six months of postformulary claims are continuing with the new injuries,‖ said DC Campbell, Director of TDI‘s Workers‘
Compensation Research and Evaluation Group.
Among the key findings are the following:
● The number of injured employees receiving N-drugs fell by 67 percent (60 percent in the previous
report);
● N-drug costs fell by 82 percent (80 percent in the previous report);
● N-drug costs as a percentage of all drug costs decreased by 79 percent (76 percent in the previous
report);
● The total number of N-drug prescriptions fell by 74 percent (69 percent previously) while it fell by 4
percent for other drugs (1 percent previously); and
● The generic substitution rate for N-drugs increased from 59 percent in 2010 to 72 percent in 2011
(from 52 percent to 68 percent in the previous report).
The report noted that there has been a 15 percent reduction in costs associated with all prescription drugs in the
Texas workers‘ compensation system for 2010 – 2011. During the same of time, there has been a 45 percent
reduction in costs of N-drug prescriptions.
The WCREG reported that there has been a 9 percent drop in the number of prescriptions written in 2010 and
2011. 500,034 prescriptions were written in 2010 compared to 452,757 prescriptions in 2011. There has been a
74% percent drop in the number of N-drug prescriptions written during the same time period. 41,281 N-drug
prescriptions were written in 2010 as compared to only 10,651 in 2011.
Page 51
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national legal directory Martindale-Hubbell and is promoted by
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Adjusters. In addition the firm is recognized by the International
Society of Primerus law firms.
Providing insurers with quality legal
representation in workers’ compensation
claims and proceedings.
With Offices in Dallas and Austin, our docket
covers all venues throughout Texas.
Dallas
http://www.downsstanford.com/
* Unless indicated in the individual attorney biographies, not
certified by the Texas Board of Legal Specialization
Downs • Stanford maintains a strong presence before the Texas Workers' Compensation
Commission. Our attorneys are highly trained in the requirements of the Texas Labor
Code and the Rules of the Texas Workers' Compensation Commission. This expertise
covers both the "Old Law" and the "New Law". We are prepared to handle all aspects of
workers' compensation claims ranging from legal consultation on a specific claim issue,
medical dispute resolution, defending administrative violations, and the prosecution and
defense of judicial review matters and matters before the State Office of Administrative
Hearings.
We actively represent numerous insurance carriers, third-party administrators, employers
and certified self-insurers for all types of hearings before the Texas Workers' Compensation Commission, including Benefit Review Conferences, Contested Case Hearings
and appeals to the Appeals Panel of the Texas Workers' Compensation Commission. We
maintain an active trial docket of workers' compensation cases that have been appealed
beyond the Texas Workers' Compensation Commission into judicial review.
Austin
Downs • Stanford maintains a high success rate on workers' compensation trials. We
have also successfully defended our client‘s interests before the Court of Appeals.
Downs • Stanford also provides a full service Board Representative Service to further
service all aspects of an insurer and self-insured company before the Texas Workers
Compensation Commission.
Our expertise covers all types of workers' compensation claims ranging from back strains
to complex multi-chemical sensitivity claims.
Page 52
DWC Sought Input on Development of Legacy Claims Pain Management Plan-Based Audit
The Texas Department of Insurance‘s Division of Workers‘
Compensation (DWC) sought input and suggestions regarding the
development of a new Plan-Based Audit for health care providers
prescribing status ―N‖ drugs on legacy claims. The Plan-Based Audit
sets the scope, methodology, selection criteria, and program area
responsibilities as laid out in the Medical Quality Review Process. A
copy of the proposed Legacy Claims Pain Management Plan-Based
Audit can be found on the DWC‘s website.
The DWC‘s Medical Advisor approved a Medical Quality Review
Annual Audit Plan which was adopted by the Commissioner of
Workers‘ Compensation. This Plan-Based Audit is from one of the
categories listed on the Medical Quality Review Annual Audit Plan. A
copy of the approved Medical Quality Review Annual Audit Plan can
be viewed on the DWC‘s website.
Input and suggestions for the legacy claims pain management plan-based Audit had to be submitted to the
DWC‘s Office of Medical Advisor via e-mail to [email protected] by 5 p.m. Central Standard Time on
Wednesday, July 31, 2013.
DWC Sets Discount and Interest Rates for July 1, 2013 through September 30, 2013
On June 20, 2013, the Texas Department of Insurance‘s (TDI) Division of Workers‘ Compensation (DWC) set
the discount and interest rates provided for by Section 401.023 of the Texas Labor Code at the rate of 3.63%.
The DWC‘s notice of the new discount and interest rates can be found on TDI‘s website.
The rate is computed by the DWC by using the treasury constant maturity rate for one-year treasury bills
(0.13%) issued by the U.S. government and published by the Federal Reserve Board on June 16, 2013 plus
3.5% as required by the Texas Labor Code.
The new rate is in effect July 1, 2013 through September 30, 2013. The rate in effect for the previous period of
April 1, 2013 through June 30, 2013 was 3.64%.
A listing of past discount and interest rates can be found on the DWC website.
Information about the workers‘ compensation discount and interest rates is also available on the DWC website
at: http://www.tdi.texas.gov/wc/carrier/index.html#discountinfo.
Does Your Company Provide Vendor and Other Services to Insurance Companies?
If your answer is YES, contact Mark Hanna, ICT‘s Manager of Public Affairs and Membership, at
[email protected] and inquire about how you can become an associate member of the
Insurance Council of Texas.
Page 53
Page 54
On July 22, 2013, the Texas Department of Insurance‘s
Division of Workers‘ Compensation (DWC) announced
that a new Deputy Commissioner of Hearings has been
hired and will assume his new position on September 3,
2013. Commissioner of Workers‘ Compensation Rod
Bordelon announced that he had selected Kerry D. Sullivan
as the new Deputy Commissioner of Hearings.
Prior to joining the DWC, Sullivan spent most of his
professional career with the State Office of Administrative
Hearings (SOAH), where he served as General Counsel
and as an administrative law judge. Mr. Sullivan was also
appointed SOAH‘s first Master Administrative Law Judge and held other management positions at the agency.
Following his retirement from SOAH, Mr. Sullivan worked as Litigation Counsel for the Texas State Board of
Pharmacy. Sullivan received a bachelor‘s degree from Texas Tech University and a law degree from
University of Texas School of Law.
Dan Barry, who served as Acting Deputy Commissioner for Hearings, will return full-time to his role as head
of the DWC‘s Appeals Panel.
DWC Seeks Input on Maximum Hourly Rate for Attorneys and
Legal Assistants Handling Workers’ Compensation Cases
Insurance Industry Opposes Increase in Maximum Hourly Rate
The Texas Department of Insurance‘s Division of Workers‘
Compensation (DWC) published a concept draft rule proposal
regarding attorney fee guidelines for legal services provided to
claimants and insurance carriers. The DWC sought input from
system stakeholders on whether or not the maximum hourly rate
for attorneys and legal assistants should be increased or remain at
the current rates of $150 for attorneys and $50 for legal assistants.
The current Rule 152.4 was adopted in 1991 and set the maximum
hourly rate for attorneys and legal assistants at the current rates.
The maximum hour rate has not been increased since it was
established in 1991.
Attorneys who represent injured employees and insurance carriers have both expressed their desire that the
maximum hourly rate be increased. One attorney, John D. Pringle of Austin, Texas, recommended that the
DWC create a State average maximum hourly rate based on an average that injured employee‘s attorneys are
being awarded as an hourly rate by the Division in Labor Code Section 408.147(c) cases.
―The Division should also create a State average maximum hourly rate based on an average that Plaintiff‘s
attorneys are being awarded as an hourly rate by the Courts in Labor Code Section 408.221(c) cases,‖ said
Pringle. ―These two state averages should then be averaged and the result would be the maximum hourly rate.‖
Page 55
Pringle also said the DWC should amend Rule 152.4 to provide that the DWC shall consider the following
factors, which are not exclusive, when approving attorney‘s fees:
(1) the time and labor required;
(2) the novelty and difficulty of the questions involved;
(3) the skill required to perform the legal services properly;
(4) the fee customarily charged in the locality for similar legal services;
(5) the amount involved in the controversy;
(6) the benefits to the claimant that the attorney is responsible for securing; and
(7) the experience and ability of the attorney performing the services.
Pringle also commented on and recommended changes to the table included in Rule 152.4 which sets out the
guidelines for legal services provided to injured employees and insurance carriers.
The Office of Injured Employee Counsel (OIEC), which assists injured employees at DWC benefit and
medical dispute resolution proceedings submitted comments supporting an increase in the maximum hourly
rate for attorneys and legal assistants
The American Insurance Association, Insurance Council of Texas, and Property and Casualty Insurers of
America all weighed in on the concept informal draft rule on behalf of the insurance industry. All three
insurance trade associations submitted comments reporting that their member insurance companies were
opposed to increasing the maximum hourly rate for attorneys and legal assistants‘ fees.
DWC Announces New Test and Test Administration Vendor to
Certify Maximum Medical Improvement and Permanent Impairment
On May 1, 2013, the Texas Department of Insurance‘s Division of Workers‘ Compensation (DWC) announced
the development of new examinations to test designated doctors and doctors seeking authorization to certify
maximum medical improvement and permanent impairment. Effective May 1, 2013, the new examinations will
be the only examinations approved by the DWC for certification or recertification of designated doctors and
doctors authorized to certify maximum medical improvement and permanent impairment.
The new examinations can only be taken at PSI testing locations and will no longer be administered onsite
following the certification training sessions. The first day for administration of the new examinations will be
May 13, 2013. To schedule an examination, designated doctors and doctors seeking authorization to certify
maximum medical improvement and permanent impairment must visit the PSI website at
http://www.psiexams.com or contact PSI by calling (800) 733-9267.
Pledge Your Support to ICT’s Scholarship Program Today
Together We can Make a Difference
Information about the Insurance Council of Texas Education
Foundation and how you can become a contributor is available on our website.
Page 56
Page 57
DWC Proposes Repealing Rules Considered To Be No Longer Necessary
The Texas Department of Insurance‘s Division of Workers‘ Compensation (DWC) proposes the repeal of
several rules it has deemed no longer necessary. The determination that the rules are no longer necessary was
made during a recent review of the rules.
The DWC has proposed the repeal of the following rules:
Chapter or Rule Number and Title
Memo Explaining Reason for Repeal
Rule 41.50, Access to Board Records
Memo
Rule 43.15, Sanctions
Memo
Rule 43.20, Required Information to Insureds
Memo
Chapter 89, Crime Victims Compensation Act
Memo
Chapter 103, Subchapter A and Rules103.1-103.3 and
103.100, Subchapter B and Rule 103.101, Subchapter
C and Rules 103.300-103.322, and Subchapter D and
Rule 103.400, Agency Administration
Memo
The DWC has also proposed amending Rule 102.8, relating to Information Requested on Written
Communications to the Commission. The DWC reported that the proposed amendments are necessary to
update the terminology used in the rule and to delete a subsection that refers to another section that has been
repealed.
Comments on the proposed repeal of the above referenced rules and amendments to Rule 102.8 were required
to be filed with the DWC no later than 5 p.m. Central Standard, August 5, 2013.
DWC Reminds System Participants of Pharmacy Informal and
Voluntary Network Registration and Reporting Requirements
On June 21, 2013, the Texas Department of Insurance‘s Division
of Workers‘ Compensation (DWC) published a memo to remind
system participants about the requirement for informal and
voluntary pharmacy networks to register with the DWC not later
than thirty days after the network is established and must report
any changes in information previously reported to the DWC
within thirty days of the change.
The failure of a pharmacy informal or voluntary network to
comply with the registration requirements is an administrative
violation.
A copy of the memo can be found on the DWC‘s website.
The DWC reminder noted that pharmacy informal and voluntary
networks must report the information required by §408.0282 of
Page 58
the Texas Labor Code to the DWC through its online reporting system that can be found on the TDI website.
For further information on this registration process, system participants should refer to the DWC‘s Frequently
Asked Questions on this topic found on the TDI website.
The DWC reminded insurers, their authorized agents, and/or the pharmacy informal or voluntary networks that
§408.0281 of the Texas Labor requires them to notify each health care provider, at least quarterly of any person,
other than the injured employee, to which the network‘s contractual fee arrangements with the health care
providers are sold, leased, transferred or conveyed. The notice must contain certain information listed in
§408.0281(d) of the Texas Labor Code and the delivery of the notice must be documented.
The initial notice must be sent to health care providers not later than the 30th day after the effective date of the
health care provider‘s contract and subsequent notices sent on a quarterly basis thereafter. The failure to comply
with the provisions of §408.0281 of the Texas Labor Code is an administrative violation. The DWC reminded
insurance carriers that they are responsible for any sanction imposed for violations, regardless of whether the
insurance carrier or its authorized agent committed the act or acts of noncompliance.
The DWC also reminded system participants that prescription medications or services may not be delivered by a
certified workers‘ compensation health care network under Texas Insurance Code Chapter 1305 or by a political
subdivision that directly contracts with health care providers pursuant to §504.053(b)(2) of the Texas Labor
Code.
What is a pharmacy informal network?
§408.0281(a) of the Texas Labor Code defines a pharmacy informal network as a network established under a
contract between an insurance carrier or an insurance carrier‘s authorized agent and health care provider for the
provision of pharmaceutical services, that includes a specific fee schedule.
What is a pharmacy voluntary network?
§408.0281(a) of the Texas Labor Code defines a pharmacy voluntary network as a voluntary workers‘
compensation health care delivery network established under former §408.0223 of the Texas Labor Code, as
that section existed before repeal by Chapter 265 (House Bill 7, 79th Legislature, Regular Session, 2005) by an
insurance carrier for the provision of pharmaceutical services.
Additional Information About Pharmaceutical Benefits in the Texas Workers’ Compensation System
In the Texas workers‘ compensation system, pharmacy benefits are based on a series of rules that are entitled,
Pharmaceutical Benefits (28 Texas Administrative Code (TAC) §134.500 through §134.550). These rules cover
commonly used definitions, initial pharmaceutical coverage, prescribing of generics and over-the-counter drugs
in addition to brand name drugs, a pharmacy fee guideline, open and closed formularies, rules pertaining to the
transition to a closed formulary from an open formulary, and other pharmaceutical provisions.
Understanding the rules for pharmacy services and related resources, including the requirements for pharmacy
informal and voluntary network online registration, are crucial to the clinically appropriate prescribing of
prescriptions and successful reimbursement for both claims subject to certified networks, and claims not subject
to certified networks.
Additional information about pharmaceutical benefits in the Texas workers‘ compensation system can be found
here.
Page 59
Texas Business Indicted on Workers’ Compensation Fraud Charges
On August 1, 2013, Texas Mutual Insurance Company announced that a Travis County grand jury indicted
Mark Edward Helm and McClanahan Drywall, Inc., of Emory, Texas, on workers' compensation fraud-related
charges.
Helm was an officer of McClanahan Drywall, Inc. and obtained workers‘ compensation coverage through
Texas Mutual from Feb. 14, 2008, to June 7, 2009. Texas Mutual alleges that, during the periods of coverage,
Helm misrepresented the number of employees and payroll associated with the company by falsely
representing contract laborers as subcontractors.
Because workers‘ compensation insurance premium is based, in part, on payroll, this type of scheme results in
an employer being charged a lower premium than it actually owes. By hiding payroll, an employer can gain an
unfair advantage over competitors.
The indictment is the latest effort in Texas Mutual‘s on-going fight against workers‘ compensation insurance
fraud. To underscore the importance of fighting workers‘ compensation insurance fraud, it is important to note
that if workers' comp fraud were a legitimate business in the United States, it would rank among the Fortune
500 companies. Indeed, according to the National Insurance Crime Bureau, workers' compensation fraud totals
$7.2 billion a year—more than Yahoo! Inc.'s revenue in 2007. The Texas Department of Insurance notes that
insurance fraud is the second most profitable crime after drug trafficking.
Editor’s Note: A grand jury indictment is a formal accusation, not a conviction, of criminal conduct.
DWC Announces Dates and Locations for Workers’ Compensation Educational Conferences
On June 20, 2013, the Texas Department of Insurance‘s Division of Workers‘ Compensation announced the
dates and locations for the agency‘s workers‘ compensation education conference. The conference will be held
in Austin and repeated in Dallas and will educate health care providers, medical office staff, employers,
employee organizations, workers‘ compensation insurance carriers, third party administrators and other Texas
workers‘ compensation system participants on the laws passed by the Texas Legislature and rules adopted by
the agency.
The Austin educational conference will be held Thursday and Friday, September 12-13, 2013 at the
Renaissance Austin Hotel, 9721 Arboretum Blvd. The Dallas educational conference will be held Monday and
Tuesday, October 21-22, 2013 at the Renaissance Dallas Richardson Hotel, 900 E. Lookout Drive in
Richardson. Registration is $325 per person through August 1, 2013 and $375 per person after August 1, 2013.
The registration fee includes conference materials and breakfast and lunch served on the second day of the
conferences.
Not an Associate Member of the Insurance Council of Texas?
Does your company or firm provide vendor or other services to property and casualty insurers? If so, your
company or firm may be eligible to join the Insurance Council of Texas and become part of the collective voice
of the insurance industry in Texas.
Contact Mark Hanna at [email protected] or Steve Nichols at [email protected] to find
out how you can become an associate member of the Insurance Council of Texas.
Page 60
Page 61
Texas Companies Receive Safety Award at Texas Safety Summit
The Texas Department of Insurance, Division of Workers‘
Compensation (DWC) recognized two Texas employers,
CFAN and BeautiControl, with the Peer Review Safety
Program Award for their exemplary occupational safety and
health programs on May 15, 2013 at the 17th Annual Safety
and Health Conference, the Texas Safety Summit, in Austin.
CFAN manufactures turbine fan blades and other
components of General Electric jet engines at its facility in
San Marcos. As a three-time recipient of this award, CFAN
has created an outstanding safety culture that fosters high
quality and active participation in the safety program by all
levels of its 586 employees. The company also participates in
the Occupational Safety and Health Administration‘s (OSHA) Voluntary Protection Program (VPP).
BeautiControl manufactures cosmetics, face and body creams, and skin treatments at their facility in Carrollton.
A first-time recipient of this award, BeautiControl has created an excellent safety culture with a top-to-bottom
commitment to maintaining the safest possible workplace for its 130 employees, as evidenced by their policies,
procedures, and workplace safety performance.
The DWC Peer Review Safety Program recognizes Texas employers that have comprehensive safety programs.
Once approved, these programs can serve as models or standards of comparison for employers developing or
reviewing their own workplace safety programs. Companies are nominated or can self-nominate, and may
qualify for the award by having proven safety programs in place and injury and illness incidence rates below the
national averages for their industries.
For more information about the Peer Review Safety Program, visit the TDI website or call 512-804-4610.
NCCI Outlook on Workers Compensation Industry: "Encouraging"
On May 16, 2013, NCCI released its annual State of the Line workers compensation market analysis,
describing the current state of the industry as "encouraging." This year's report indicates that the workers
compensation calendar combined ratio was 109 in 2012, a six-point decrease from 2011 and the first decrease
since 2006.
"By many measures, the industry condition is indeed improving," said NCCI President and CEO Steve Klingel.
"While we are pleased to see that the positives are beginning to outweigh the negatives, there remains great
opportunity for improvement. Our optimism is tempered by knowing that external forces such as the economy,
healthcare reform, and new legislation may still negatively affect the market. But for now, we view the overall
industry condition as encouraging."
"The workers compensation line continues to deal with a variety of significant challenges. These include poor
underwriting results, low investment yields, and continued uncertainty regarding the impact of the
implementation of the federal healthcare reform bill," added NCCI Chief Actuary Dennis Mealy. "But despite
the long-term challenges, workers compensation saw some positive developments in 2012. Premiums grew for
the second consecutive year, the combined ratio declined six points, and claim frequency continued to improve
at a pace slightly greater than its long-term historic rate of decline."
Page 62
As noted above, the workers compensation calendar year combined ratio for private carriers was 109 for 2012.
Although a 109 combined ratio is far from satisfactory, the decline is welcome. And the accident year
combined ratio experienced a similar six-point improvement. NCCI estimates that the accident year combined
ratio for 2012 is 108, following 114 in 2011.
In other good news, lost-time claim frequency improved significantly in 2012—down 5% on average in NCCI
states. The 5% decline is slightly larger than NCCI's long-term annual estimate of a of 2–4% decline per year.
Previous NCCI research indicated that distortions in the calendar year premium data resulting from the
recession and subsequent recovery affected our measure of claim frequency for 2010 and 2011. Current
research indicates that those distortions are no longer significant for 2012.
Other market indicators/trends highlighted in NCCI's 2011 State of the Line report include the following:
● Net written premium (including state funds) increased to $39.63 billion in 2012. This 9% increase
follows an 8% increase in 2011. This is a welcome shift following the cumulative 27% decline in
premium from 2006–2010.
● The impact on premium of changes to bureau loss cost/rate filings was about 2 percent in NCCI
states for 2012. For 2013, the impact of bureau loss cost/rate filings is basically flat in NCCI states.
In the last filing cycle, NCCI filed 25 increases and 13 decreases, mostly for effective dates in 2013.
Carrier discounting from bureau loss costs and rates declined about 2.5% in 2012 in NCCI states.
About 40% of the increase in premiums in 2012 can be attributed to increases in bureau loss costs
and rates, and the decline in carrier discounting.
● The private carrier reserve position continued to deteriorate in 2012 for the fifth consecutive year.
NCCI's estimate of the reserve position for the private carriers as of Year-End 2012 is a $13 billion
deficiency.
● Investment returns for the workers compensation line remained strong. For the third consecutive
year, the ratio of investment gains on insurance transactions to premium was at or above 14%.
● Investment results combined with underwriting results produced a workers‘ compensation pretax
operating gain of 5% for 2012. This is in-line with the industry's long-term average, and a welcome
improvement following three years of near-zero operating gains or losses.
● In NCCI states, the average indemnity cost per lost-time claim increased a modest 1% in 2012, after
increasing 2% in 2011 and declining 3% in 2010.
● The average medical cost per lost-time claim increased by 3% in 2012 after increasing 3.6% in 2011
and increasing 1.4% in 2010. Combined, the total lost-time claim cost increased about 2% in 2012,
which is about the same rate as the change in average wages.
● The workers compensation residual market experienced significant growth in 2012. Premiums grew
by close to 50%, and the average market share in the residual market increased from 5% to 7%. The
pace of growth is continuing into the first quarter of 2013.
● Although the volume of business in the residual market is growing as the market tightens, the
combined ratio actually improved from 117 in Policy Year 2011 to 112 in 2012. The total
underwriting loss in the residual market pools serviced by NCCI was $99 million for Policy Year
2012, up slightly from the $85 million in 2011.
Page 63
Looking Ahead
In 2012, the workers compensation line showed some signs of recovery. Results improved materially,
including the following:
● The combined ratio for workers compensation improved for the first time since 2006;
● Premium grew for the second consecutive year ; and
● Claim frequency declined significantly for the first time since 2009 claim severity increases
remained modest.
Even with the improvements, workers compensation is faced with some ongoing challenges:
● The combined ratio, while lower, still remains too high;
● Slow growth in employment, particularly in the manufacturing and construction industries, is
impeding additional premium growth; and
● In addition, the impact of the implementation of the Patient Protection and Affordable Care Act in
2014 looms as a huge uncertainty for the line.
The entire NCCI State of the Line presentation can be found on NCCI‘s website. A moderated presentation is
of NCCI‘s State of the Line is available here.
NCCI‘s 2013 Workers’ Compensation Issues Report is available on NCCI‘s website.
For more information about NCCI's State of the Line report, please visit ncci.com or contact NCCI Media
Relations Director Gregory Quinn at 607-723-7878 or [email protected].
Medical Services for Claims 20 or More Years Old Will Likely Account for More
Than 10 Percent of the Cost of Medical Benefits for Workplace Injuries in 2013
NCCI study reported that it is likely that more than 10% of the cost of medical benefits for the workplace
injuries that occur this year will be for services provided more than two decades into the future. That
percentage has been growing and might continue to grow according to NCCI.
The study by NCCI looks at workers compensation medical services provided beyond 20 years after the injury,
with a view toward anticipating:
● which medical service categories will account for the largest shares of costs; and
● future treatment and utilization that will drive those costs.
The NCCI study first looks at the demographics of claimants who are still being treated for job-related injuries
that were suffered more than two decades ago. The focus then shifts from patients to their medical care,
looking at medical costs by service and diagnosis categories.
Page 64
Some key findings concerning services provided from 20 to 30 years following the date of injury are as
follows:
● Patients are predominantly male, more so than can be explained by historical gender differences in
the workforce;
● Deteriorating medical conditions of the more elderly claimants is not a main cost driver; indeed,
claimants younger than age 60 cost more per year, per claimant, to treat than those older than age 60;
● Relative to services within the first 20 years after injury, care provided later has a significantly
greater portion of cost going for prescription medications, supplies, home health services, and the
maintenance of implants, orthotics, and prosthetics.
The NCCI Research Brief regarding medical services provided beyond 20 years or more after the injury
is available at https://www.ncci.com/documents/Med-Svcs-20yrs.pdf.
American Insurance Association Backs Legislation to Extend Terrorism Risk Insurance Program
In February 2013, Representatives Michael Grimm (R-NY), Carolyn Maloney (D-NY), Pete Sessions (R-TX),
André Carson (D-IN), Peter King (R-NY), Gregory Meeks (D-NY), Dennis Ross (R-FL), Timothy Bishop (DNY), and Carolyn McCarthy (D-NY) introduced the ―TRIA Reauthorization Act of 2013‖ to extend the
Terrorism Risk Insurance Program for five years, through December 31, 2019. Two additional pieces of
legislation were subsequently filed to extend the Terrorism Risk Insurance Program
On May 9, 2013, Representatives Bennie Thompson (D-MS) introduced the ―Fostering Resilience to Terrorism
Act of 2013 which would extend the Terrorism Risk Insurance Act (TRIA) for 10 years, designates the U.S.
Department of Homeland Security to become the ―lead‖ agency in the certification process, and adds a
provision on information sharing for the insureds. Representative Thompson is the Ranking Member of the
U.S. House of Representatives‘ Committee on Homeland Security.
On May 23, 2013, the ―Terrorism Risk Insurance Program Reauthorization Act of 2013‖ was filed by U.S.
Representatives Michael Capuano (D-MA) and Peter King (R-NY) along with 19 co-sponsors. The legislation
would extend the Terrorism Risk Insurance Act (TRIA) for 10 years. Representative Capuano is the Ranking
Member on the U.S. House of Representatives‘ Housing and Insurance Subcommittee. Representative King
serves on the U.S. House of Representatives‘ Committees for Homeland Security and Financial Services.
TRIA, which was first authorized in 2002, subsequently reauthorized in 2005 and 2007, is scheduled to expire
on December 31, 2014.
In response to the filing of the ―Terrorism Risk Insurance Program Reauthorization Act of 2013,‖ Leigh Ann
Pusey, president and CEO of the American Insurance Association (AIA), released a statement in support of
the legislation and the extension of the Terrorism Risk Insurance Act.
Continued on Page 62.
Be Part of the Solution. Help Stop Prescription Drug
Abuse in the Texas Workers’ Compensation System
Report Prescription Drug Abuse and Illegal Prescriptions
Page 65
A Sponsor of ICT’s October 3, 2013 Workers’ Compensation Conference
Page 66
“AIA thanks Representatives Capuano and King for their leadership on this important issue, especially in the
aftermath of the bombings in Boston,‖ said Pusey. ―As key members of the House Financial Services and the
Homeland Security Committees, their efforts will be of primary importance.‖
Pusey said the Terrorism Risk Insurance Program continues to protect our nation‘s economy. ―In the years
since September 11, 2001, the program has provided much needed market stability and predictability for an
orderly recovery after an event,‖ said Pusey. ―The bill protects taxpayers by requiring insurers to meet
significant deductibles and includes a mandatory recoupment provision for federal dollars expended.‖
Pusey said AIA looks forward to working with House Insurance Subcommittee Chairman Randy Neugebauer
(R-TX), Ranking Member Mike Capuano, and the entire Committee in the months ahead as AIA seeks to
achieve a broadly-supported bipartisan TRIA reauthorization bill prior to the program‘s 2014 expiration.
What Does the Future Hold for the Terrorism Risk Insurance Act?
Prior to the September 11, 2001, terrorist attacks, insurance coverage for losses from such attacks was
normally included in general insurance policies without specific cost to the policyholders. Following the
attacks, such coverage became very expensive if insurers offered it at all. Because insurance is required for a
variety of economic transactions, it was feared that the absence of insurance against terrorism loss would have
a wider economic impact. Terrorism insurance was largely unavailable for most of 2002, and some have
argued that this adversely affected parts of the economy.
Congress responded to the disruption in the terrorism insurance market by passing the Terrorism Risk
Insurance Act of 2002 (TRIA; P.L. 107-297, 116 Stat. 2322). TRIA created a temporary three-year Terrorism
Insurance Program in which the government would share some of the losses with private insurers should a
foreign terrorist attack occur. This program was extended in 2005 (P.L. 109-144, 119 Stat. 2660) and 2007
(P.L. 110-160, 121 Stat. 1839). The amount of government loss sharing depends on the size of the insured loss.
In general terms, for a relatively small loss, private industry covers the entire loss. For a medium-sized loss, the
federal role is to spread the loss over time and over the entire insurance industry; the government assists
insurers initially but then recoups the payments through a broad levy on insurance policies afterwards. For
a large loss, the federal government would cover most of the losses, although recoupment is possible in these
circumstances as well. Insurers are required to make terrorism coverage available to commercial policyholders,
but TRIA does not require policyholders to purchase the coverage. The prospective government share of losses
has been reduced over time compared with the initial act, but the 2007 reauthorization expanded the program
to cover losses from acts of domestic terrorism.
The TRIA program is currently slated to expire at the end of 2014. The specifics of the current program are as
follows:
(1) a single terrorist act must cause $5 million in damage to be certified for TRIA coverage;
(2) the aggregate insured loss from certified acts of terrorism must be $100 million in a year for the
government coverage to begin; and
(3) an individual insurer must meet a deductible of 20% of its annual premiums for the government
coverage to begin. Once these thresholds are passed, the government covers 85% of
insured losses due to terrorism. If aggregate insured losses due to terrorism do not exceed
$27.5 billion, the Secretary of the Treasury is required to recoup 133% of the government
coverage by the end of 2017 through surcharges on property/casualty insurance policies. If the
losses exceed $27.5 billion, the Secretary has discretion to apply recoupment surcharges.
Page 67
Since TRIA‘s passage, the private industry‘s willingness and ability to cover terrorism risk have increased.
According to industry surveys, prices for terrorism coverage have generally trended downward, and
approximately 60% of commercial policyholders have purchased coverage over the past few years. This
relative market calm has been under the umbrella of TRIA coverage, and it is unclear how the insurance
market would react to the expiration of the federal program.
In the 113th Congress, three bills, H.R. 508, H.R. 1945, and H.R. 2146, have been introduced to extend the
TRIA program. H.R. 508 would extend the program‘s expiration date five years, until 2019. H.R. 1945 would
extend the program 10 years, until 2024, and add the Secretary of Homeland Security as the lead authority for
certifying an act of terrorism. H.R. 2146 would extend the program‘s expiration date 10 years, until 2024.
A report by the Congressional Research Services published on March 24, 2013 analyzes and provides an
overview of the current TRIA and is available here.
Workers’ Compensation Insurers Are Closely Monitoring Legislative Efforts to Extend TRIA
Risk & Insurance recently reported that with the current TRIA set to expire in December 2014, the insurance
industry is gearing up for congressional battles. Those in the workers' compensation market are especially
interested in seeing the program continue.
Risk & Insurance noted that whether TRIA expires, is amended, or even continues as is, insurers will need to
take action. Certain endorsements would need to be revised, for example, and language on assigned risk
binders and quotes would need to reflect TRIA's current name, according to an FAQ document on NCCI's
website.
Risk & Insurance also reported that the passage of a TRIA extension would be welcome news for workers'
compensation insurers, but noted the industry is getting prepared for all possible outcomes. While the issue is
especially significant for workers' comp, the loss of TRIA would also impact other areas of the financial
marketplace. According to Risk & Insurance, that could ultimately bode well for the chances of TRIA
continuing.
International Terrorism Against the U.S., 1969 – 2009: Fatalities and Injuries
Fatalities
Standard
Deviation
0.9
2.2
0.3
3.1
0.9
0.8
0.9
2.1
1.0
8.6
7.0
22.5
0.4
1.1
0.0
0.0
596.4
1,205.8
0.0
0.0
0.0
00.0
Mean
Armed Attack
Arson
Assassination
Barricade/Hostage
Bombing
Hijacking
Kidnapping
Other (non-classified)
Unconventional Attack
Excluding 911
Unknown
Median
Number
0.0
0.0
1.0
0.0
0.0
0.0
0.0
0.0
44.0
0.0
0.0
396
96
91
21
1,903
26
225
14
5
2
3
Mean
Standard
Deviation
1.1
4.1
0.0
0.3
0.3
0.6
2.2
4.8
7.0
121.8
6.2
25.2
0.1
0.3
0.7
2.4
467.4
1,003.2
0.00
0.0
0.00
0.0
Injuries
Median
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Number
395
95
89
21
1,914
26
222
14
5
2
3
Source: Calculations by the Heritage Foundation‘s Center for Data Analysis based on data from RAND Database
of Worldwide Terrorism Incidents at http://www.rand.org/nsrd/projects/terrorism-incidents.htm. (April 18, 2011).
Page 68
Page 69
DWC Announces Approval of Eleven Requests for Renewal of Certificates of Authority to Self-Insure
On July 30, 2013, the Texas Department of Insurance‘s Division of Workers‘ Compensation (DWC) announced that
they had approved eleven renewals of the Certificates of Authority for companies to self-insure their workers‘
compensation claims for a one-year period under the DWC Self-Insurance Program. These companies collectively
employ approximately 40,800 employees in Texas.
Under Texas law, certain large, private companies can self-insure for workers‘ compensation claims, while retaining
the protection of the Texas Workers‘ Compensation Act for the company and for its employees. To qualify, a
company must have a minimum workers‘ compensation insurance unmodified manual premium of $500,000 and
meet other requirements subject to annual review.
The following companies received self-insurance certificates:
● Baker Concrete Construction, Inc., Monroe, OH
● Chevron Corporation, San Ramon, CA
● Driver Pipeline Company, Inc., Irving
● General Motors Company, Detroit, MI
● Johns Manville, Denver, CO
● Kiewit Corporation, Omaha, NE
● L Brands, Inc., Columbus, OH
● MasTec, Inc., Coral Gables, FL
● MeadWestvaco Corporation, Richmond, VA
● Starbucks Corporation, Seattle, WA
●Trinity Mother Frances Health System, Tyler
For more information on applying to the Self-Insurance Regulation program, visit the DWC website at
http://www.tdi.texas.gov/wc/si/index.html.
Mineral Wells Man Sentenced for Workers’ Comp Fraud
On August 15, 2013, Texas Mutual Insurance Company reported that a Travis County district court sentenced
Michael Shane Schmidt of Mineral Wells, Texas on workers‘ compensation fraud-related charges. The court
sentenced Schmidt to one year of deferred adjudication and ordered him to pay $2,649 in restitution to Texas
Mutual.
Schmidt reported a job-related injury while working as a truck driver for E.L. Farmer and Company in Odessa,
Texas. He claimed he was unable to work as a result of the injury, and Texas Mutual began paying income
benefits to him.
Texas Mutual uncovered evidence that Schmidt was working as a truck driver for another company while
receiving income benefits due to his alleged disability.
Investigators call this type of scam double-dipping because the claimant collects benefits for being too injured
to work when he or she is, in fact, gainfully employed. Texas law requires claimants to contact their workers‘
comp carrier when they return to work. Left unchecked, double-dipping and other workers‘ comp fraud can lead
to higher premiums for all Texas employers.
Editor’s Note – A grand jury indictment is an accusation, not a conviction, of criminal conduct.
Page 70
Employers see more workers compensation claims in August than any other month, according to Travelers’
data.
August is the most dangerous month of the year when it comes to on-the–job injuries, according to an analysis
of Travelers Companies, Inc.‘s (Travelers) claim data in Texas from the past two years. Texas employers filed
more workers compensation claims in August than any other month. These claims are often from injuries that
may be avoided, including strains, sprains, lacerations and contusions. With this data in mind, Travelers is
helping Texas employers take the necessary steps to keep their workers safe.
Employees are the backbone of any successful company, so it is important that employers take steps to keep
them healthy and safe at work,‖ said Kim Bittle, Regional Vice President, Travelers. ―The good news is many
of these injuries are avoidable, and business owners can take advantage of risk management tools that help
them build effective safety strategies in the workplace.‖
A company can reduce its financial exposure to a workplace accident by ensuring it has workers compensation
insurance in place. However, according to the Texas Department of Insurance, one-third of all businesses in
Texas are non-subscribers to the workers compensation system. For small business owners, a single on-the-job
accident could cripple their operations if they are not covered. An independent insurance agent can help
business owners learn more about what coverage is needed for their particular business and industry.
To help businesses promote worker safety, Travelers recommends that employers take the following:
● Establish an integrated safety culture – Visible evidence of a commitment to safety can be shown
through top management‘s attendance at safety meetings, their review and action on accident reports
and establishing an employee-managed safety committee.
● Implement a safety management program – A comprehensive safety program should address worker
security and overall safety.
● Educate and train – Avoiding injuries can be improved with proper safety orientations, regular safety
coaching from an effective mentor and regular communication.
● Hire the right person for the job – Selecting skilled, safe, dependable employees is the first step in
establishing an organization‘s safety culture.
For additional information on managing risks and workers compensation insurance, visit www.travelers.com.
Texas Census of Fatal Occupational Injuries in 2012 (Preliminary Results) Announced
Nationally, there were a total of 4,383 fatal work injuries in 2012, according to preliminary data released on
August 22, 2013 by the U.S. Department of Labor, Bureau of Labor Statistics (BLS), Census of Fatal
Occupational Injuries (CFOI). The fatality rates were highest in the construction, transportation, agriculture,
and mining and oil and gas extraction industries. In Texas, there were 531 work-related fatalities, an increase
from 2011.
Incidence rates for nonfatal injuries and illnesses by industry for 2012 will be published in October 2013. In
2011, the Texas incidence rate for nonfatal occupational injuries and illnesses was 2.7 per 100 full-time
workers. The Texas non-fatal rate has been below the national average since data collection began in 1990.
Detailed findings are available at http://www.tdi.texas.gov/news/2013/news201331.html.
Page 71
Page 72
Associate Member of the Insurance Council of Texas
Page 73
WORKERS’ COMPENSATION NEWS BRIEFS
Austin, Texas, August 5, 2013 – The Texas Department of Insurance‘s Division of Workers‘ Compensation
published a memorandum regarding the passage of Senate Bill 1322, relating to the provision of durable
medical equipment (DME) and home health care services through informal and voluntary networks. The
memorandum informed stakeholders of specific requirements on reimbursement for DME and home health
care services for non-network claims, network claims, and claims administered by political subdivisions in the
Texas workers‘ compensation system.
Austin, Texas, August, 2013 – The Office of Injured Employee Counsel published two documents with
recommendations on how to reform the Texas workers‘ compensation system. The first document, titled
Recommendations for Reformation of the Texas Workers’ Compensation System, and the second document,
titled Suggestions for Solutions to Workers' Compensation Issues. The OIEC concluded in their first document
that ―the system now in place is not working and it is time for the debate about how to reform workers‘
compensation to begin.‖ The OIEC‘s documents included several recommendations on how to ―fix‖ the Texas
workers‘ compensation system.
Camarillo, California, July 16, 2013 – WorkCompCentral reported that lawyers and insurance carriers are
many dollars apart on attorney fee cap. The article reports on an informal draft concept rule published by the
DWC and the comments on the informal draft rules filed by attorneys and the insurance industry. (Subscription
Required).
San Diego, California, July 15, 2013 – The Insurance Journal published an article titled ―No Bad Faith in
Worker’s Compensation Context.‖ The article reports on a second decision rendered by the Texas Supreme
Court that issued a decision finding that no private right of action for an insurer‘s unfair claims settlement
practices in the workers‘ compensation context – Texas Mut. Ins. Co. v. Morris, 383 S.W.3d 146 (Tex. 2012).
The Morris decision was pending before the Texas Supreme Court when it issues the Court‘s decision in Texas
Mut. Ins. Co. v. Ruttiger, 381 S.W.3d 430 (Tex. 2012), and held that a claimant could not recover damages
under Texas‘ Unfair Claims Settlement Practices Act (Ins. Code § 541.060) from a workers‘ compensation
insurer for unfair claims settlement practices. Ruttiger, 381 S.W.3d at 445.
Austin, Texas, July 8, 2013 – Texas Mutual Insurance Company announced that the Texas Alliance of Energy
Producers (TAEP) safety group has earned a $398,735 workers‘ compensation dividend, and the Lone Star
Energy (LSE) safety group earned a $124,962 dividend. Both dividends were based largely on each group‘s
collective workplace safety record.
Austin, Texas, June 21, 2013 – The Texas Department of Insurance‘s Division of Workers‘ Compensation
(DWC) announced enforcement actions taken in June 2013. The DWC entered enforcement letters to 11 system
participants that include six insurers/payers, a designated doctor, and 3 health care providers. The acts of noncompliance that triggered the enforcement action included failing to timely comply with an order of the DWC,
failure to provide on-site visits and other accident prevention services for policyholders, and failing to timely
pay income benefits to an injured employee, and improperly billing an injured employee for workers' compensation medical services provided.
Boca Raton, Florida, May 16, 2013 – NCCI published an overview of the update to its workers‘ compensation
prescription drug study. The study focused on service year 2011. NCCI reported that on a nation-wide basis,
narcotics account for 25% of all prescription drug costs. The report noted that 47% of narcotics costs are for
drugs with Oxycodone HCL as an active ingredient.
Page 74
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Page 76
DWC Finalizes Health Care Providers Pain Management (Opioid) Plan-Based Audit
On April 10, 2012 the Texas Department of Insurance‘s
Division of Workers‘ Compensation (DWC) solicited and
received constructive input from workers‘ compensation
system participants on its initial plan to audit opioid
utilization in the Texas workers‘ compensation system. All
comments were considered and discussed by DWC staff
and the Office of the Medical Advisor. In response to the
input received from system stakeholders, the DWC has
revised the proposed Health Care Providers Pain Management (Opioid) Plan-Based Audit. . The revised plan has
been approved by Commissioner Rod Bordelon on May 29,
2013.
The approved Health Care Providers Pain Management
(Opioid) Plan-Based Audit will focus on the opioid
prescribing patterns of health care providers that are
inconsistent with treatment recommendations outlined in the
DWC‘s adopted treatment guidelines – The Official
Disability Guidelines - Treatment in Work Comp (ODG)
published by the Work loss Data Institute. Specifically, the Opioid Plan-Based Audit will review the top fifteen
health care providers (in terms of claim volume) who have prescribed opioids to employees injured in Calendar
Year 2010 where the initial opioid prescription was less than 10 days from the date of injury; the total day
supply of opioids for the injured employee is greater than 30 days; and the health care provider audit subject
was the only health care provider prescribing opioids to the injured employee during the audit timeframe.
In response to comments received on the draft audit plan, the DWC will include surgical claims in this initial
audit. However, any claims that had a surgical procedure in the first 60 days from the date of injury will be
excluded in order to focus attention on those claims where the medical necessity and appropriateness of opioid
use is questionable.
The Medical Quality Review Panel will assess the medical necessity and appropriateness of prescribing opioids
in cases selected for this Plan-Based Audit by using their professional expertise and knowledge, in addition to:
● the ODG treatment guidelines;
● the return-to-work guidelines adopted by the DWC – the Medical Disability Advisor, Workplace
Guidelines for Disability Duration published by the Reed Group) for return-to-work outcomes;
● nationally recognized, evidence-based medicine standards;
● generally accepted standard of care; and
● any other relevant information.
All medical quality reviews initiated on or after January 1, 2011 will be performed in accordance with the
approved procedure.
h
Page 77
The National WWII Museum in New Orleans opened on June 6, 2000, as The National
D-Day Museum. Founded by historian and author, Stephen Ambrose, the Museum tells
the story of the American Experience in the war that changed the world — why it was
fought, how it was won, and what it means today — so that all generations will
understand the price of freedom and be inspired by what they learn.
Designated by the U.S. Congress in 2003 as the America‘s National WWII Museum, the
campus includes the Louisiana Memorial Pavilion, showcasing large artifacts of the war
and exhibits on D-Day at Normandy, the Home Front and the Pacific; the Solomon
Victory Theater, a 4-D theater showing the exclusive Tom Hanks production, Beyond
All Boundaries; the Stage Door Canteen, where the music and entertainment of the
―Greatest Generation‖ comes to life; the John E. Kushner Restoration Pavilion where
staff and volunteers restore artifacts in public view; and the American Sector restaurant
and Soda Shop — delicious onsite dining options by Chef John Besh.
2
The museum founder, historian Stephen E. Ambrose‘s (January 10, 1936 – October 13,
2002) efforts resulted in the opening of an unparalleled museum in New Orleans,
Louisiana. Ambrose wrote an acclaimed, multi-volume biography of Dwight "Ike"
Eisenhower‘s presidency and his service as the Supreme Commander of the Allied
assault on Nazi Germany. Ambrose also other bestseller history books about World War
II. These include: Band of Brothers, D-Day, Wild Blue and Citizen Soldiers. He was the
military advisor for the movie Saving Private Ryan and served as an executive producer
for the award winning HBO mini-series Band of Brothers.
Stephen Ambrose inspired and guided the development of The National WWII Museum
until his passing in 2002. His dream of a museum honoring our nation‘s ―Greatest
Generation‖ reflected his deep regard for our nation‘s citizen soldiers, the workers on the
Home Front and the sacrifices and hardships they endured to achieve victory.
Help Honor America’s Greatest Generation
The generation of Americans who came to adulthood during the 1930s grew up in a
world shadowed by extraordinary economic and military threats. A financial depression
gripped much of the globe, throwing millions out of work. In some countries, economic
hardship contributed to the power and appeal of political extremists. These leaders
offered simple solutions to their countries' problems, solutions that included extreme
nationalism, military expansion, and doctrines of racial superiority. America‘s ―Greatest
Generation‖ answered the call to arms. They fought, defeated the Axis powers and
preserved Democracy.
In September of 2012, the National WWII Museum joined with the Insurance
Council of Texas to honor the Texas insurance industry‘s WWII veterans.
View NOLA TV‘s video about The National World War II Museum Here and the
museum‘s Fly-Thru Video Here. Listen to Drew Brees and Tom Hanks talk about the
National WWII Museum. Plan your visit to the museum today.
Help the Museum tell the story of our nation‘s World War II veterans.
A Sponsor of ICT’s 2012 Luncheon Honoring the Insurance Industry’s World War II Veterans
Page 78
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Page 79
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Page 80
FDA Approves Abuse-Deterrent Labeling for Reformulated OxyContin
On April 16, 2013, the U.S. Food and Drug Administration (FDA) announced that the agency had approved
updated labeling for Purdue Pharma L.P.‘s reformulated OxyContin (oxycodone hydrochloride controlledrelease) tablets. The new labeling indicates that the product has physical and chemical properties that are
expected to make abuse via injection difficult and to reduce abuse via the intranasal route (snorting).
Additionally, because original OxyContin provides the same therapeutic benefits as reformulated OxyContin,
but poses an increased potential for certain types of abuse, the FDA has determined that the benefits of original
OxyContin no longer outweigh its risks and that original OxyContin was withdrawn from sale for reasons of
safety or effectiveness. Accordingly, FDA announced that the agency will not accept or approve any
abbreviated new drug applications (generics) that rely upon the approval of original OxyContin.
The FDA approved the original formulation of OxyContin in December of 1995. The product was abused, often
following manipulation intended to defeat its extended-release properties. Such manipulation causes the drug to
be released more rapidly, which increases the risk of serious adverse events, including overdose and death. In
April 2010, the FDA approved a reformulated version of OxyContin, which was designed to be more difficult to
manipulate for purposes of misuse or abuse. Purdue stopped shipping original OxyContin to pharmacies in
August 2010.
―The development of abuse-deterrent opioid analgesics is a public health priority for the FDA,‖ said Douglas
Throckmorton, M.D., deputy director for regulatory programs in the FDA‘s Center for Drug Evaluation and
Research. ―While both original and reformulated OxyContin are subject to abuse and misuse, the FDA has
determined that reformulated OxyContin can be expected to make abuse by injection difficult and expected to
reduce abuse by snorting compared to original OxyContin.‖
The FDA has determined that the reformulated product has abuse-deterrent properties. The tablet is more difficult
to crush, break, or dissolve. It also forms a viscous hydrogel and cannot be easily prepared for injection. The
agency has determined that the physical and chemical properties of the reformulated product are expected to
make the product difficult to inject and to reduce abuse via snorting. However, abuse of OxyContin by these
routes, as well as the oral route, is still possible. The reformulated product also may reduce incidents of therapeutic misuse, such as crushing the product to sprinkle it onto food or to administer it through a gastric tube. When
FDA finds that a new formulation has abuse deterrent properties, the agency has the authority to require generics
to have abuse-deterrent properties also.
Postmarketing assessments of the impact of reformulated OxyContin on abuse are ongoing, and the FDA will
update its evaluation of the effects of reformulated OxyContin on abuse as new data become available.
The FDA, together with other public health agencies, continues to encourage the development of abuse-deterrent
formulations of opioids and believes that such products will help reduce prescription drug abuse. At the same
time, the FDA remains committed to ensuring that patients with pain have appropriate access to opioid analgesics.
Did You Know?
The Insurance Council of Texas (ICT) publishes an Appeals Panel Decisions Digest that includes summaries of
significant decisions. The electronic manual, prepared in conjunction with the Austin-based law firm of Burns,
Anderson Jury Brenner, L.L.P., is available to ICT‘s member-ship as a member‘s only benefit. If you are employed
by a member company of ICT, contact Steve Nichols to obtain access to the manual.
Not a member, inquire about joining ICT by contacting Mark Hanna at 512.444.0911 or via e-mail.
Page 81
Workers’ Compensation Insurance Fraud Is A Problem!
What is Insurance Fraud?
Insurance fraud is an intentional deception committed by applicants,
policyholders, claimants, providers, agents and company employees. It
may occur during the process of buying, using, selling or underwriting
insurance and is usually motivated by greed.
Insurance Fraud is a crime in Texas!
Workers‘ Compensation insurance fraud is a problem.
The National Insurance Crime Bureau (NICB) has reported that
studies indicate up to 10 percent--perhaps more--of all property/
casualty insurance claims are fraudulent. The NICB has also
estimated that workers' comp fraud costs the insurance industry as
much as $5 billion annually.
Workers‘ compensation fraud includes the padding of bills by health
care providers, injured employees claiming injuries that do not occur,
employers falsely classifying employees in different occupations to
obtain lower premiums, and injured employees receiving income
replacement benefits while working.
We Need Your Help!
“Disabled” Injured Worker Playing Golf
The Texas Committee on Insurance Fraud needs your help in fighting
workers‘ compensation fraud.
You can help us fight workers‘ compensation insurance fraud by
reporting it to the Texas Department of Insurance at 1-888-372-8818.
Online Reporting of Fraud Available
“Disabled” Injured Worker Changing a
Flat Tire
Online reporting of insurance fraud is available at:
http://www.tdi.state.tx.us/fraud/frsiufrrpt.html.
Take a bite out of crime by reporting workers‘ compensation insurance
fraud.
Get Involved with the Texas Committee on Insurance
Fraud
Contact Mark Hanna at (512) 444-9611 or at the following e-mail
address [email protected] to become involved in the
Texas Committee on Insurance Fraud.
Help Us Fight Workers’ Compensation Insurance Fraud
Page 82
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Page 83
An Associate Member of the Insurance Council
Page 84
Significant Texas Case Law Update From WorkCompCentral
Piland v. Harris County, 14-12-00087-CV, (01/15/2013): An employer successfully recouped its workers'
compensation benefits from a third-party suit by filing a breach-of-contract suit several months before the
statute of limitations expired, a Texas appellate court ruled. See case decision here.
Cervantes v. New Hampshire Insurance Co., 04-12-00722-CV, (7/10/13): A designated doctor‘s medical report
confirming a claimants maximum medical improvement date and impairment rating complied with Division of
Workers Compensation rules, Texas 4th Court of Appeals concluded. See case decision here.
Brooks v. The Goodyear Tire Rubber Co., 14-12-01048-CV, (07/09/2013): A company that was contractually
obligated to reimburse a contractor‘s workers compensation premiums, and satisfied its obligations, qualified
as the statutory employer of the contractors injured employee, the Texas 14th Court of Appeals ruled. See case
decision here.
City of Dallas v. Salyer, 05-12-00701-CV, (07/02/2013): A worker provided by a staffing agency to the City of
Dallas could not sue the city in tort for injuries he sustained when a dump truck backed into him since he
qualified as an "employee" of the city and the city provided workers compensation coverage to its employees.
See case decision here.
City of Bellaire v. Johnson, 11-0933, (06/07/2013): A precedential 2012 decision prevented a borrowed
employee from suing a city employer for a work-related amputation injury, even though he was not covered by
the city‘s workers compensation policy, the Texas Supreme Court ruled. See case decision here.
Vista Medical Center Hospital v. Texas Mutual Insurance Co., 03-11-00641-CV through 03-11-00643-CV,
and Nos. 03-11-00742-CV through 03-11-00785-CV, (06/06/2013): The Texas Department of Insurances
Division of Workers Compensation has exclusive jurisdiction to resolve disputes between a medical care
provider and an insurance carrier about the payment due to the provider for its services to injured workers. See
case decision here.
Rico v. Judson Lofts, 04-12-00330-CV, (05/29/2013): The 4th Court of Appeals, San Antonio, Texas revived
an injured construction workers tort claim against the company that had leased his services, concluding there
was a triable issue of fact as to whether the borrowing employer was covered by the employee-leasing
company‘s workers compensation policy. See case decision here.
WorkCompCentral Offers Workers’ Comp Research Library for Texas and Much More
If you have a full access paid subscription to WorkCompCentral, as opposed to a news only subscription, you
can access the WorkCompCentral Research Library - TX. In order to access this resource, you must first log
in, then click on Law in the upper horizontal menu of the site header.
WorkCompCentral was founded by David J. DePaolo in 1999. DePaolo became a member of the California State Bar in
1984 and practiced workers' compensation law in private practice with Miller & Folse, Adelson Testan Brundo &
Popalardo, and as a sole practitioner prior to starting WorkCompCentral. DePaolo holds a J.D. from Pepperdine
University School of Law (1984), a Masters in Business Administration from California Lutheran University (1997)
and a Bachelor of Arts, English, from San Diego State University (1981).
WorkCompCentral reports on developments impacting workers‘ compensation systems in all 50 states and
the District of Columbia and offers online continuing education courses in several states.
Page 85
3200 Highland Avenue
Downers Grove, IL 60515
(630) 737-7900
[email protected]
Coventry WC Network Services, a business segment of Coventry Health Care Workers' Comp Services, Inc. ("Coventry
Workers' Comp Services"), is the comprehensive outsourcing solution for containing health care and disability costs.
Serving the occupational health care market, Coventry Workers‘ Comp Services provides employers, insurers and claims
payors with a variety of integrated health care services. These services include in-network and out-of-network medical
claims review and re-pricing, access to specialized Preferred Provider Organizations ("PPOs"), early intervention and case
management-driven Return-To-Work ("RTW") services and other cost management and related services.
Recently formed from the combination of First Health and Concentra‘s Workers‘ Compensation Cost Management
businesses, Coventry Workers‘ Comp Services delivers increased medical, indemnity and administrative (―total cost‖)
savings by offering our customers a fully integrated suite of services.
Coventry WC Networks have focused our workers‘ compensation expertise, technology and work process re-engineering
resources to deliver the following value to our customers:
Increased cost savings (medical and total costs)
Improved communications and quality of decision-making
Service innovation, consistency and reliability
Increased information accuracy and usefulness; and
Increased frequency of superior claims outcomes.
With more than three decades of experience and as one of the industry leaders in our field, Coventry WC Network
Services provides services that successful reduce the high cost of workers‘ compensation medical and total costs while
delivering improved claims outcomes for injured workers, employers, third-party administrators and insurers.
Coventry WC Network Services reviews, re-prices, and reduces medical bills received by claims payors (third-partyadministrators and insurers) and also achieves customer savings through fee negotiation and access to PPO networks.
Document management solutions and Adjuster Desktop informational interfaces contribute proven capabilities that
facilitate adjuster effectiveness and improve the timeliness and flow of meaningful information to support both better
decision-making and lower operating costs.
Visit us online at http://www.coventrywcnetworks.com/.
Page 86
Page 87
The Property Casualty Insurers Association of America (PCI) provides a
responsible and effective voice on public policy questions affecting
insurance products and services in an effort to foster a competitive
insurance marketplace for the benefit of insurers and consumers. The
proverbial adage ―strength in numbers‖ rings true at our association, for
no insurance company can solely create the type of influence, wealth of
information and networking opportunities that PCI provides. Our
greatest value to members is the ability to save companies time and
money by creating individual and collective victories through a healthier
legislative and regulatory environment. Members benefit from the
advocacy, knowledge, networking and value that PCI offers.
Advocacy: The unmatched skills of PCI staff and local lobbyists, a
group that includes former state legislators and commissioners,
enables the association to inform and influence state and federal
public policy makers. Retained lobbyists are used in each state to
advocate PCI positions on issues. Expert staff exists at PCI
headquarters in Des Plaines, our federal government affairs office in
Washington, D.C., and regional offices in Albany, Atlanta, Austin,
Boston, Denver, Harrisburg, Tallahassee, Trenton, Seattle and
Sacramento to better manage industry activity.
Knowledge: The information members receive is specifically targeted
to their interests. Our more than 80 publications — including bulletins,
committee communications, reference and research documents and
statistical analysis — enlighten members with understanding that is
necessary to stay on top of new industry activities.
In particular, the Legislative Database tracks thousands of bills and
regulations each year, reporting on their introduction, enactment, and
court challenges. This service analyzes and interprets effects of bills and
regulations on insurers — saving members the cost of noncompliance.
Besides the written word, the sharing of information takes place through
seminars, where industry experts editorialize and clarify issues, and
committee meetings that facilitate information sharing among members.
Networking: Gleaning competitive tips from peer-to-peer contact leads
to peak performance. PCI provides a multitude of opportunities to meet
with colleagues and establish new business associates each year through
its 8 seminars and numerous committee meetings. PCI has at least one
member headquartered in each of the 50 states, bringing more contacts,
knowledge and expertise to the association — and creating partnerships
across the nation.
Enhance your business, your bottom line, your industry environment. E-mail [email protected] or call
her at 847-553-3634.
Copyrighted Publication of the Insurance Council of Texas August 28, 2013
Page 88
INSURANCE COUNCIL OF TEXAS
Become An Associate Member Today
The Insurance Council of Texas (ICT) is a multi-purpose, non-profit
trade association of property and casualty insurers writing business in
Texas. ICT's purpose is to provide a mechanism through which our
members and associate members can collectively represent their interests
in the regulatory process and stay abreast of those events that affect the
business of insurance in Texas.
Our Accomplishments
● ICT is an opinion leader in the Texas
workers‘ compensation system.
● ICT has commented on every new rule
proposed by the state‘s workers‘
compensation regulatory agency and
shaped the rules that have been adopted.
● ICT provides our membership with
timely analysis of new laws and rules
not available from any other source.
More information about our workers‘
compensation program is available on ICT‘s
website.
Our experienced and knowledgeable staff provides a variety of services
and products that give our member companies the information and
resources they need to be successful in the Texas insurance marketplace.
ICT does not lobby, but follows the legislative process and reports to the
membership on important legislative initiatives and changes in insurance
law. We are regular participants in regulatory matters and employ an
active committee system to guide our involvement.
ICT‘s Workers‘ Compensation Services program provides our members
and associate members with representation before the Texas Department
of Insurance (TDI) and the TDI Division of Workers‘ Compensation on
regulatory matters, timely reports on developments impacting the Texas
workers‘ compensation system and information not available from any
other source.
Associate Membership Benefits
■ Your company/firm would join the collective voice of ICT's 500
plus member insurance companies and a growing number of
associate members;
■ Access to ICT's "members only" website;
■ Access for an unlimited number of company/firm staff members
to our workers' compensation newsletter, association newsletter,
workers' compensation bulletins and other insurance lines
bulletins, and our members-only confidential legislative report;
■ ICT‘s Workers‘ Compensation Committee provides our members
with a forum to discuss workers‘ compensation policy issues;
■ Free access to ICT's on-line, electronic workers' compensation
manuals, e.g. Texas Workers' Compensation Law and Rules
manual and Appeals Panel Digest; and
Contact Mark Hanna, ICT’s
Manager of Public Affairs, at (512)
444-9611 to obtain additional
information about joining ICT.
■ New associate members and associate members who renew their
membership are entitled to have a full-page, multi-color advertisement in each edition of the Texas Workers' Compensation
Update newsletter.
Visit Us Online at http://www.insurancecouncil.org/.
Page 89
Page 90
Workers’ Compensation Events Calendar
Texas Department of Insurance
Public Meetings and Hearings
The Texas Department of Insurance (TDI) does not currently have any meetings or hearings scheduled.
Stakeholder Meetings
The Texas Department of Insurance has no stakeholder meetings scheduled at this time.
Division of Workers’ Compensation
DWC Annual Education Conference
The DWC will host its 2013 Workers‘ Compensation Education Conference on September 12-13, 2013 in
Austin, Texas and October 21-22, 2013 in Richardson, Texas.
Public Meetings and Hearings
The Division of Workers‘ Compensation (DWC) does not currently have any public meetings or hearings
scheduled.
Stakeholder Meetings
The Division of Workers‘ Compensation (DWC) does not currently have a stakeholder meetings scheduled.
The DWC continues to hold a series of educational seminars for doctors and other stakeholders throughout
Texas. The event dates and locations are available on the Agency Calendar on the TDI website.
2014 Mid-Year Property & Casualty Insurance Symposium
ICT and AFACT will host the 2014 Mid-Year Property & Casualty Insurance Symposium in Austin, Texas
on July 17, 2014. Registration for this event will be available on ICT‘s website at a future date.
2013 Workers’ Compensation Conference
ICT will host its 2013 Workers‘ Compensation Conference in Austin, Texas on October 3, 2013. The
conference agenda and online registration for this event is available on ICT‘s website.
2014 Workers’ Compensation Seminars
ICT will host its spring seminars in 2014 in Addison, Texas (DFW Metro Area) and Austin, Texas on dates
to be determined. The seminar agenda and online registration for ICT‘s seminars will be available on ICT‘s
website at a future date.
Page 91

texas workers` compensation update

Transcription

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