LABOR CODE
CHAPTER 413. MEDICAL REVIEW
SUBCHAPTER A. DIVISION OF MEDICAL REVIEW
§ 413.001. DEFINITION. In this chapter, "division"
means the division of medical review of the commission.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.002. DIVISION OF MEDICAL REVIEW. (a) The
commission shall maintain a division of medical review to ensure
compliance with the rules and to implement this chapter under the
policies adopted by the commission.
(b) The division shall monitor health care providers,
insurance carriers, and workers' compensation claimants who
receive medical services to ensure the compliance of those persons
with rules adopted by the commission relating to health care,
including medical policies and fee guidelines.
(c) In monitoring health care providers who serve as
designated doctors under Chapter 408, the division shall evaluate
the compliance of those providers with this subtitle and with rules
adopted by the commission relating to medical policies, fee
guidelines, and impairment ratings.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1995, 74th Leg., ch. 980, § 1.42, eff. Sept. 1, 1995.
§ 413.003. AUTHORITY TO CONTRACT. The commission may
contract with a private or public entity to perform a duty or
function of the division.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.004. COORDINATION WITH PROVIDERS. The division
shall coordinate its activities with health care providers as
necessary to perform its duties under this chapter. The
coordination may include:
(1) conducting educational seminars on commission
rules and procedures; or
(2) providing information to and requesting
assistance from professional peer review organizations.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.005. MEDICAL ADVISORY COMMITTEE. (a) The
medical advisory committee advises the division in developing and
administering the medical policies, fee guidelines, and
utilization guidelines established under Section 413.011. The
committee shall advise the commission or professional organization
in the review and revision of medical policies and fee guidelines
required under Section 413.012.
(b) The medical advisory committee is composed of members
appointed by the commission as follows:
(1) a representative of a public health care facility;
(2) a representative of a private health care
facility;
(3) a doctor of medicine;
(4) a doctor of osteopathic medicine;
(5) a chiropractor;
(6) a dentist;
(7) a physical therapist;
(8) a pharmacist;
(9) a podiatrist;
(10) an acupuncturist;
(11) an occupational therapist;
(12) a medical equipment supplier;
(13) a registered nurse;
(14) a representative of employers;
(15) a representative of employees;
(16) a representative of an insurance carrier; and
(17) two representatives of the general public.
(c) Each member of the medical advisory committee must be
knowledgeable and qualified regarding work-related injuries and
diseases.
(d) The commission shall designate the presiding officer of
the medical advisory committee.
(e) The medical advisory committee shall meet at the call of
its presiding officer or at the call of a majority of the committee.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1999, 76th Leg., ch. 1426, § 17, eff. Sept. 1, 1999; Acts
2001, 77th Leg., ch. 719, § 3, eff. Sept. 1, 2001.
§ 413.006. ADVISORY COMMITTEES. The commission may
appoint advisory committees in addition to the medical advisory
committee as it considers necessary.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.007. INFORMATION MAINTAINED BY
DIVISION. (a) The division shall maintain a statewide data base
of medical charges, actual payments, and treatment protocols that
may be used by:
(1) the commission in adopting the medical policies
and fee guidelines; and
(2) the division in administering the medical
policies, fee guidelines, or rules.
(b) The division shall ensure that the data base:
(1) contains information necessary to detect
practices and patterns in medical charges, actual payments, and
treatment protocols; and
(2) can be used in a meaningful way to allow the
commission to control medical costs as provided by this subtitle.
(c) The division shall ensure that the data base is
available for public access for a reasonable fee established by the
commission. The identities of injured workers and beneficiaries
may not be disclosed.
(d) The division shall take appropriate action to be aware
of and to maintain the most current information on developments in
the treatment and cure of injuries and diseases common in workers'
compensation cases.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.008. INFORMATION FROM INSURANCE CARRIERS;
ADMINISTRATIVE VIOLATION. (a) On request from the commission for
specific information, an insurance carrier shall provide to the
division any information in its possession, custody, or control
that reasonably relates to the commission's duties under this
subtitle and to health care:
(1) treatment;
(2) services;
(3) fees; and
(4) charges.
(b) The commission shall keep confidential information that
is confidential by law.
(c) An insurance carrier commits a violation if the
insurance carrier fails or refuses to comply with a request or
violates a rule adopted to implement this section. A violation
under this subsection is a Class C administrative violation. Each
day of noncompliance constitutes a separate violation.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
SUBCHAPTER B. MEDICAL SERVICES AND FEES
§ 413.011. REIMBURSEMENT POLICIES AND GUIDELINES;
TREATMENT GUIDELINES AND PROTOCOLS. (a) The commission shall use
health care reimbursement policies and guidelines that reflect the
standardized reimbursement structures found in other health care
delivery systems with minimal modifications to those reimbursement
methodologies as necessary to meet occupational injury
requirements. To achieve standardization, the commission shall
adopt the most current reimbursement methodologies, models, and
values or weights used by the federal Health Care Financing
Administration, including applicable payment policies relating to
coding, billing, and reporting, and may modify documentation
requirements as necessary to meet the requirements of Section
413.053.
(b) In determining the appropriate fees, the commission
shall also develop conversion factors or other payment adjustment
factors taking into account economic indicators in health care and
the requirements of Subsection (d). The commission shall also
provide for reasonable fees for the evaluation and management of
care as required by Section 408.025(c) and commission rules. This
section does not adopt the Medicare fee schedule, and the
commission shall not adopt conversion factors or other payment
adjustment factors based solely on those factors as developed by
the federal Health Care Financing Administration.
(c) This section may not be interpreted in a manner that
would discriminate in the amount or method of payment or
reimbursement for services in a manner prohibited by Section 3(d),
Article 21.52, Insurance Code, or as restricting the ability of
chiropractors to serve as treating doctors as authorized by this
subtitle. The commission shall also develop guidelines relating to
fees charged or paid for providing expert testimony relating to an
issue arising under this subtitle.
(d) Guidelines for medical services fees must be fair and
reasonable and designed to ensure the quality of medical care and to
achieve effective medical cost control. The guidelines may not
provide for payment of a fee in excess of the fee charged for
similar treatment of an injured individual of an equivalent
standard of living and paid by that individual or by someone acting
on that individual's behalf. The commission shall consider the
increased security of payment afforded by this subtitle in
establishing the fee guidelines.
(e) The commission by rule may adopt treatment guidelines,
including return-to-work guidelines, and individual treatment
protocols. Except as otherwise provided by this subsection, the
treatment guidelines and protocols must be nationally recognized,
scientifically valid, and outcome-based and designed to reduce
excessive or inappropriate medical care while safeguarding
necessary medical care. If a nationally recognized treatment
guideline or protocol is not available for adoption by the
commission, the commission may adopt another treatment guideline or
protocol as long as it is scientifically valid and outcome-based.
(f) The commission by rule may establish medical policies or
treatment guidelines or protocols relating to necessary treatments
for injuries.
(g) Any medical policies or guidelines adopted by the
commission must be:
(1) designed to ensure the quality of medical care and
to achieve effective medical cost control;
(2) designed to enhance a timely and appropriate
return to work; and
(3) consistent with Sections 413.013, 413.020,
413.052, and 413.053.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 6.02, eff. June 17, 2001;
Acts 2003, 78th Leg., ch. 962, § 1, 2, eff. June 20, 2003.
§ 413.012. MEDICAL POLICY AND GUIDELINE UPDATES
REQUIRED. The medical policies and fee guidelines shall be
reviewed and revised at least every two years to reflect fair and
reasonable fees and to reflect medical treatment or ranges of
treatment that are reasonable or necessary at the time the review
and revision is conducted.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.013. PROGRAMS. The commission by rule shall
establish:
(1) a program for prospective, concurrent, and
retrospective review and resolution of a dispute regarding health
care treatments and services;
(2) a program for the systematic monitoring of the
necessity of treatments administered and fees charged and paid for
medical treatments or services, including the authorization of
prospective, concurrent, or retrospective review under the medical
policies of the commission to ensure that the medical policies or
guidelines are not exceeded;
(3) a program to detect practices and patterns by
insurance carriers in unreasonably denying authorization of
payment for medical services requested or performed if
authorization is required by the medical policies of the
commission; and
(4) a program to increase the intensity of review for
compliance with the medical policies or fee guidelines for any
health care provider that has established a practice or pattern in
charges and treatments inconsistent with the medical policies and
fee guidelines.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.014. PREAUTHORIZATION REQUIREMENTS; CONCURRENT
REVIEW AND CERTIFICATION OF HEALTH CARE. (a) In this section,
"investigational or experimental service or device" means a health
care treatment, service, or device for which there is early,
developing scientific or clinical evidence demonstrating the
potential efficacy of the treatment, service, or device but that is
not yet broadly accepted as the prevailing standard of care.
(b) The commission by rule shall specify which health care
treatments and services require express preauthorization or
concurrent review by the insurance carrier. Treatments and
services for a medical emergency do not require express
preauthorization.
(c) The commission rules adopted under this section must
provide that preauthorization and concurrent review are required at
a minimum for:
(1) spinal surgery, as provided by Section 408.026;
(2) work-hardening or work-conditioning services
provided by a health care facility that is not credentialed by an
organization recognized by commission rules;
(3) inpatient hospitalization, including any
procedure and length of stay;
(4) outpatient or ambulatory surgical services, as
defined by commission rule; and
(5) any investigational or experimental services or
devices.
(d) The insurance carrier is not liable for those specified
treatments and services requiring preauthorization unless
preauthorization is sought by the claimant or health care provider
and either obtained from the insurance carrier or ordered by the
commission.
(e) The commission may not prohibit an insurance carrier and
a health care provider from voluntarily discussing health care
treatment and treatment plans and pharmaceutical services, either
prospectively or concurrently, and may not prohibit an insurance
carrier from certifying or agreeing to pay for health care
consistent with those agreements. The insurance carrier is liable
for health care treatment and treatment plans and pharmaceutical
services that are voluntarily preauthorized and may not dispute the
certified or agreed-on preauthorized health care treatment and
treatment plans and pharmaceutical services at a later date.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 4.02, eff. June 17, 2001;
Acts 2003, 78th Leg., ch. 980, § 1, eff. Sept. 1, 2003.
§ 413.0141. INITIAL PHARMACEUTICAL COVERAGE. The
commission may by rule provide that an insurance carrier shall
provide for payment of specified pharmaceutical services
sufficient for the first seven days following the date of injury if
the health care provider requests and receives verification of
insurance coverage and a verbal confirmation of an injury from the
employer or from the insurance carrier as provided by Section
413.014. The rules adopted by the commission shall provide that an
insurance carrier is eligible for reimbursement for pharmaceutical
services paid under this section from the subsequent injury fund in
the event the injury is determined not to be compensable.
Added by Acts 2001, 77th Leg., ch. 1456, § 4.03, eff. June 17,
2001.
§ 413.015. PAYMENT BY INSURANCE CARRIERS; AUDIT AND
REVIEW. (a) Insurance carriers shall make appropriate payment of
charges for medical services provided under this subtitle. An
insurance carrier may contract with a separate entity to forward
payments for medical services. Any payment due the insurance
carrier from the separate entity must be made in accordance with the
contract. The separate entity is subject to the direction of the
insurance carrier, and the insurance carrier is responsible for the
actions of the separate entity under this subsection.
(b) The commission shall provide by rule for the review and
audit of the payment by insurance carriers of charges for medical
services provided under this subtitle to ensure compliance of
health care providers and insurance carriers with the medical
policies and fee guidelines adopted by the commission.
(c) The rules must require the insurance carrier to pay the
expenses of the review and audit.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 6.03, eff. June 17, 2001.
§ 413.016. PAYMENTS IN VIOLATION OF MEDICAL POLICIES AND
FEE GUIDELINES. (a) The division shall order a refund of charges
paid to a health care provider in excess of those allowed by the
medical policies or fee guidelines. The division shall also refer
the health care provider alleged to have violated this subtitle to
the division of compliance and practices.
(b) If the division determines that an insurance carrier has
paid medical charges that are inconsistent with the medical
policies or fee guidelines adopted by the commission, the division
shall refer the insurance carrier alleged to have violated this
subtitle to the division of compliance and practices. If the
insurance carrier reduced a charge of a health care provider that
was within the guidelines, the insurance carrier shall be directed
to submit the difference to the provider unless the reduction is in
accordance with an agreement between the health care provider and
the insurance carrier.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.017. PRESUMPTION OF REASONABLENESS. The
following medical services are presumed reasonable:
(1) medical services consistent with the medical
policies and fee guidelines adopted by the commission; and
(2) medical services that are provided subject to
prospective, concurrent, or retrospective review as required by the
medical policies of the commission and that are authorized by an
insurance carrier.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.018. REVIEW OF MEDICAL CARE IF GUIDELINES
EXCEEDED. (a) The commission by rule shall provide for the
periodic review of medical care provided in claims in which
guidelines for expected or average return to work time frames are
exceeded.
(b) The division shall review the medical treatment
provided in a claim that exceeds the guidelines and may take
appropriate action to ensure that necessary and reasonable care is
provided.
(c) The commission shall implement a program to encourage
employers and treating doctors to discuss the availability of
modified duty to encourage the safe and more timely return to work
of injured employees. The commission may require a treating or
examining doctor, on the request of the employer, insurance
carrier, or commission, to provide a functional capacity evaluation
of an injured employee and to determine the employee's ability to
engage in physical activities found in the workplace or in
activities that are required in a modified duty setting.
(d) The commission shall provide through the commission's
health and safety information and medical review outreach programs
information to employers regarding effective return to work
programs. This section does not require an employer to provide
modified duty or an employee to accept a modified duty assignment.
An employee who does not accept an employer's offer of modified duty
determined by the commission to be a bona fide job offer is subject
to Section 408.103(e).
(e) The commission may adopt rules and forms as necessary to
implement this section.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1999, 76th Leg., ch. 956, § 3, eff. Sept. 1, 1999.
§ 413.019. INTEREST EARNED FOR DELAYED PAYMENT, REFUND,
OR OVERPAYMENT. (a) Interest on an unpaid fee or charge that is
consistent with the fee guidelines accrues at the rate provided by
Section 401.023 beginning on the 60th day after the date the health
care provider submits the bill to an insurance carrier until the
date the bill is paid.
(b) Interest on a refund from a health care provider accrues
at the rate provided by Section 401.023 beginning on the 60th day
after the date the provider receives notice of alleged overpayment
from the insurance carrier until the date the refund is paid.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.020. COMMISSION CHARGES. The commission by rule
shall establish procedures to enable the commission to charge:
(1) an insurance carrier a reasonable fee for access
to or evaluation of health care treatment, fees, or charges under
this subtitle; and
(2) a health care provider who exceeds a fee or
utilization guideline established under this subtitle or an
insurance carrier who unreasonably disputes charges that are
consistent with a fee or utilization guideline established under
this subtitle a reasonable fee for review of health care treatment,
fees, or charges under this subtitle.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.021. RETURN-TO-WORK COORDINATION
SERVICES. (a) An insurance carrier shall, with the agreement of a
participating employer, provide the employer with return-to-work
coordination services as necessary to facilitate an employee's
return to employment. The insurance carrier shall notify the
employer of the availability of return-to-work coordination
services. In offering the services, insurance carriers and the
commission shall target employers without return-to-work programs
and shall focus return-to-work efforts on workers who begin to
receive temporary income benefits. These services may be offered
by insurance carriers in conjunction with the accident prevention
services provided under Section 411. 061. Nothing in this section
supersedes the provisions of a collective bargaining agreement
between an employer and the employer's employees, and nothing in
this section authorizes or requires an employer to engage in
conduct that would otherwise be a violation of the employer's
obligations under the National Labor Relations Act (29 U.S.C.
Section 151 et seq.), and its subsequent amendments.
(b) Return-to-work coordination services under this section
may include:
(1) job analysis to identify the physical demands of a
job;
(2) job modification and restructuring assessments as
necessary to match job requirements with the functional capacity of
an employee; and
(3) medical or vocational case management to
coordinate the efforts of the employer, the treating doctor, and
the injured employee to achieve timely return to work.
(c) An insurance carrier is not required to provide physical
workplace modifications under this section and is not liable for
the cost of modifications made under this section to facilitate an
employee's return to employment.
(d) The commission shall use certified rehabilitation
counselors or other appropriately trained or credentialed
specialists to provide training to commission staff regarding the
coordination of return-to-work services under this section.
(e) The commission shall adopt rules necessary to collect
data on return-to-work outcomes to allow full evaluations of
successes and of barriers to achieving timely return to work after
an injury.
(f) Repealed by Acts 2003, 78th Leg., 3rd C.S., ch. 10, §
1.02(a).
Added by Acts 2001, 77th Leg., ch. 1456, § 3.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., 3rd C.S., ch. 10, §
1.02(a), eff. Oct. 20, 2003.
SUBCHAPTER C. DISPUTE RESOLUTION
§ 413.031. MEDICAL DISPUTE RESOLUTION. (a) A party,
including a health care provider, is entitled to a review of a
medical service provided or for which authorization of payment is
sought if a health care provider is:
(1) denied payment or paid a reduced amount for the
medical service rendered;
(2) denied authorization for the payment for the
service requested or performed if authorization is required or
allowed by this subtitle or commission rules;
(3) ordered by the commission to refund a payment
received; or
(4) ordered to make a payment that was refused or
reduced for a medical service rendered.
(b) A health care provider who submits a charge in excess of
the fee guidelines or treatment policies is entitled to a review of
the medical service to determine if reasonable medical
justification exists for the deviation. A claimant is entitled to a
review of a medical service for which preauthorization is sought by
the health care provider and denied by the insurance carrier. The
commission shall adopt rules to notify claimants of their rights
under this subsection.
(c) In resolving disputes over the amount of payment due for
services determined to be medically necessary and appropriate for
treatment of a compensable injury, the role of the commission is to
adjudicate the payment given the relevant statutory provisions and
commission rules. The commission shall publish on its Internet
website its medical dispute decisions, including decisions of
independent review organizations, and any subsequent decisions by
the State Office of Administrative Hearings. Before publication,
the commission shall redact only that information necessary to
prevent identification of the injured worker.
(d) A review of the medical necessity of a health care
service requiring preauthorization under Section 413.014 or
commission rules under that section shall be conducted by an
independent review organization under Article 21.58C, Insurance
Code, in the same manner as reviews of utilization review decisions
by health maintenance organizations. It is a defense for the
insurance carrier if the carrier timely complies with the decision
of the independent review organization.
(e) Except as provided by Subsections (d), (f), and (m), a
review of the medical necessity of a health care service provided
under this chapter or Chapter 408 shall be conducted by an
independent review organization under Article 21.58C, Insurance
Code, in the same manner as reviews of utilization review decisions
by health maintenance organizations. It is a defense for the
insurance carrier if the carrier timely complies with the decision
of the independent review organization.
(e-1) In performing a review of medical necessity under
Subsection (d) or (e), the independent review organization shall
consider the commission's health care reimbursement policies and
guidelines adopted under Section 413.011 if those policies and
guidelines are raised by one of the parties to the dispute. If the
independent review organization's decision is contrary to the
commission's policies or guidelines adopted under Section 413.011,
the independent review organization must indicate in the decision
the specific basis for its divergence in the review of medical
necessity. This subsection does not prohibit an independent review
organization from considering the payment policies adopted under
Section 413.011 in any dispute, regardless of whether those
policies are raised by a party to the dispute.
(f) The commission by rule shall specify the appropriate
dispute resolution process for disputes in which a claimant has
paid for medical services and seeks reimbursement.
(g) In performing a review of medical necessity under
Subsection (d) or (e), an independent review organization may
request that the commission order an examination by a designated
doctor under Chapter 408.
(h) The insurance carrier shall pay the cost of the review
if the dispute arises in connection with a request for health care
services that require preauthorization under Section 413.014 or
commission rules under that section.
(i) Except as provided by Subsection (h), the cost of the
review shall be paid by the nonprevailing party.
(j) Notwithstanding Subsections (h) and (i), an employee
may not be required to pay any portion of the cost of a review.
(k) Except as provided by Subsection (l), a party to a
medical dispute that remains unresolved after a review of the
medical service under this section is entitled to a hearing. The
hearing shall be conducted by the State Office of Administrative
Hearings within 90 days of receipt of a request for a hearing in the
manner provided for a contested case under Chapter 2001, Government
Code (the administrative procedure law). A party who has exhausted
the party's administrative remedies under this subtitle and who is
aggrieved by a final decision of the State Office of Administrative
Hearings may seek judicial review of the decision. Judicial review
under this subsection shall be conducted in the manner provided for
judicial review of contested cases under Subchapter G, Chapter
2001, Government Code.
(l) A party to a medical dispute regarding spinal surgery
that remains unresolved after a review by an independent review
organization as provided by Subsections (d) and (e) is entitled to
dispute resolution as provided by Chapter 410.
(m) The commission by rule may prescribe an alternate
dispute resolution process to resolve disputes regarding medical
services costing less than the cost of a review of the medical
necessity of a health care service by an independent review
organization. The cost of a review under the alternate dispute
resolution process shall be paid by the nonprevailing party.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(49), eff. Sept. 1, 1995;
Acts 1995, 74th Leg., ch. 980, § 1.43, eff. Sept. 1, 1995; Acts
2001, 77th Leg., ch. 1456, § 6.04, eff. June 17, 2001; Acts
2003, 78th Leg., ch. 980, § 2, eff. Sept. 1, 2003; Acts 2003,
78th Leg., ch. 1323, § 1, eff. June 21, 2003.
SUBCHAPTER D. HEALTH CARE PROVIDERS
§ 413.041. DISCLOSURE. (a) Each health care
practitioner shall disclose to the commission the identity of any
health care provider in which the health care practitioner, or the
health care provider that employs the health care practitioner, has
a financial interest. The health care practitioner shall make the
disclosure in the manner provided by commission rule.
(b) The commission shall require by rule that a doctor
disclose financial interests in other health care providers as a
condition of registration for the approved doctor list established
under Section 408.023 and shall define "financial interest" for
purposes of this subsection as provided by analogous federal
regulations. The commission by rule shall adopt the federal
standards that prohibit the payment or acceptance of payment in
exchange for health care referrals relating to fraud, abuse, and
antikickbacks.
(c) A health care provider that fails to comply with this
section is subject to penalties and sanctions as provided by this
subtitle, including forfeiture of the right to reimbursement for
services rendered during the period of noncompliance.
(d) The commission shall publish all final disclosure
enforcement orders issued under this section on the commission's
Internet website.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 6.05, eff. June 17, 2001.
§ 413.042. PRIVATE CLAIMS; ADMINISTRATIVE
VIOLATION. (a) A health care provider may not pursue a private
claim against a workers' compensation claimant for all or part of
the cost of a health care service provided to the claimant by the
provider unless:
(1) the injury is finally adjudicated not compensable
under this subtitle; or
(2) the employee violates Section 408.022 relating to
the selection of a doctor and the doctor did not know of the
violation at the time the services were rendered.
(b) A health care provider commits a violation if the
provider violates Subsection (a). A violation under this
subsection is a Class B administrative violation.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.043. OVERCHARGING PROHIBITED; OFFENSE. (a) A
health care provider commits an offense if the person knowingly
charges an insurance carrier an amount greater than that normally
charged for similar treatment to a payor outside the workers'
compensation system, except for mandated or negotiated charges.
(b) An offense under this section is a Class A misdemeanor.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.044. SANCTIONS ON DESIGNATED DOCTOR. In addition
to or in lieu of an administrative penalty under Section 415.021 or
a sanction imposed under Section 415.023, the commission may impose
sanctions against a person who serves as a designated doctor under
Chapter 408 who, after an evaluation conducted under Section
413.002(c), is determined by the division to be out of compliance
with this subtitle or with rules adopted by the commission relating
to medical policies, fee guidelines, and impairment ratings.
Added by Acts 1995, 74th Leg., ch. 980, § 1.44, eff. Sept. 1,
1995.
SUBCHAPTER E. IMPLEMENTATION OF COMMISSION POWERS AND DUTIES
§ 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND
HEALTH CARE PROVIDERS. (a) The commission may contract with a
health care provider, health care provider professional review
organization, or other entity to develop, maintain, or review
medical policies or fee guidelines or to review compliance with the
medical policies or fee guidelines.
(b) For purposes of review or resolution of a dispute as to
compliance with the medical policies or fee guidelines, the
commission may contract with a health care provider, health care
provider professional review organization, or other entity that
includes in the review process health care practitioners who are
licensed in the category under review and are of the same field or
specialty as the category under review.
(c) The commission may contract with a health care provider,
health care provider professional review organization, or other
entity for medical consultant services, including:
(1) independent medical examinations;
(2) medical case reviews; or
(3) establishment of medical policies and fee
guidelines.
(d) The commission shall establish standards for contracts
under this section.
(e) For purposes of this section, "health care provider
professional review organization" includes an independent review
organization.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17, 2001.
§ 413.0511. MEDICAL ADVISOR. (a) The commission shall
employ or contract with a medical advisor, who must be a doctor as
that term is defined by Section 401.011.
(b) The medical advisor shall make recommendations
regarding the adoption of rules to:
(1) develop, maintain, and review guidelines as
provided by Section 413.011, including rules regarding impairment
ratings;
(2) review compliance with those guidelines;
(3) regulate or perform other acts related to medical
benefits as required by the commission;
(4) impose sanctions or delete doctors from the
commission's list of approved doctors under Section 408.023 for:
(A) any reason described by Section 408.0231; or
(B) noncompliance with commission rules;
(5) impose conditions or restrictions as authorized by
Section 408.0231(f);
(6) receive, and share with the medical quality review
panel established under Section 413.0512, confidential
information, and other information to which access is otherwise
restricted by law, as provided by Sections 413.0512, 413.0513, and
413.0514 from the Texas State Board of Medical Examiners, the Texas
Board of Chiropractic Examiners, or other occupational licensing
boards regarding a physician, chiropractor, or other type of doctor
who applies for registration or is registered with the commission
on the list of approved doctors; and
(7) determine minimal modifications to the
reimbursement methodology and model used by the Medicare system as
necessary to meet occupational injury requirements.
Added by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., ch. 963, § 1, eff. June
20, 2003.
§ 413.0512. MEDICAL QUALITY REVIEW PANEL. (a) The
medical advisor shall establish a medical quality review panel of
health care providers to assist the medical advisor in performing
the duties required under Section 413.0511. The panel is
independent of the medical advisory committee created under Section
413.005 and is not subject to Chapter 2110, Government Code.
(b) The Texas State Board of Medical Examiners and the Texas
Board of Chiropractic Examiners, with input from their respective
professional associations, shall develop lists of physicians and
chiropractors licensed by those agencies who have demonstrated
experience in workers' compensation or utilization review. The
medical advisor shall consider appointing some of the members of
the medical quality review panel from the names on those lists. The
medical advisor shall also consider nominations for the panel made
by labor, business, and insurance organizations.
(c) The medical quality review panel shall recommend to the
medical advisor:
(1) appropriate action regarding doctors, other
health care providers, insurance carriers, and utilization review
agents; and
(2) the addition or deletion of doctors from the list
of approved doctors under Section 408.023 or the list of designated
doctors established under Section 408.122.
(d) A person who serves on the medical quality review panel
is immune from suit and from civil liability for an act performed,
or a recommendation made, within the scope of the person's
functions as a member of the panel if the person acts without malice
and in the reasonable belief that the action or recommendation is
warranted by the facts known to that person. In the event of a civil
action brought against a member of the panel that arises from the
person's participation on the panel, the person is entitled to the
same protections afforded a commission member under Section
402.010.
(e) The actions of a person serving on the medical quality
review panel do not constitute utilization review and are not
subject to Article 21.58A, Insurance Code.
Added by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., ch. 963, § 2, eff. June
20, 2003.
§ 413.0513. CONFIDENTIALITY
REQUIREMENTS. (a) Information collected, assembled, or
maintained by or on behalf of the commission under Section 413.0511
or 413.0512 constitutes an investigation file for purposes of
Section 402.092 and may not be disclosed under Section 413.0511 or
413.0512 except as provided by that section
(b) Confidential information, and other information to
which access is restricted by law, developed by or on behalf of the
commission under Section 413.0511 or 413.0512 is not subject to
discovery or court subpoena in any action other than:
(1) an action to enforce this subtitle brought by the
commission, an appropriate licensing or regulatory agency, or an
appropriate enforcement authority; or
(2) a criminal proceeding.
Added by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., ch. 963, § 3, eff. June
20, 2003.
§ 413.0514. INFORMATION SHARING WITH OCCUPATIONAL
LICENSING BOARDS. (a) This section applies only to information
held by or for the commission, the Texas State Board of Medical
Examiners, and Texas Board of Chiropractic Examiners that relates
to a person who is licensed or otherwise regulated by any of those
state agencies.
(b) The commission and the Texas State Board of Medical
Examiners on request or on its own initiative, may share with each
other confidential information or information to which access is
otherwise restricted by law. The commission and the Texas State
Board of Medical Examiners shall cooperate with and assist each
other when either agency is conducting an investigation by
providing information to each other that the sending agency
determines is relevant to the investigation. Except as provided by
this section, confidential information that is shared under this
section remains confidential under law and legal restrictions on
access to the information remain in effect. Furnishing information
by the Texas State Board of Medical Examiners to the commission or
by the commission to the Texas State Board of Medical Examiners
under this subsection does not constitute a waiver of privilege or
confidentiality as established by law.
(c) Information that is received by the commission from the
Texas State Board of Medical Examiners or by the Texas State Board
of Medical Examiners from the commission remains confidential, may
not be disclosed by the commission except as necessary to further
the investigation, and shall be exempt from disclosure under
Sections 402.092 and 413.0513.
(d) The commission and the Texas Board of Chiropractic
Examiners on request or on its own initiative, may share with each
other confidential information or information to which access is
otherwise restricted by law. The commission and the Texas Board of
Chiropractic Examiners shall cooperate with and assist each other
when either agency is conducting an investigation by providing
information to each other that is relevant to the investigation.
Except as provided by this section, confidential information that
is shared under this section remains confidential under law and
legal restrictions on access to the information remain in effect
unless the agency sharing the information approves use of the
information by the receiving agency for enforcement purposes.
Furnishing information by the Texas Board of Chiropractic Examiners
to the commission or by the commission to the Texas Board of
Chiropractic Examiners under this subsection does not constitute a
waiver of privilege or confidentiality as established by law.
(e) Information that is received by the commission from the
Texas Board of Chiropractic Examiners or by the Texas Board of
Chiropractic Examiners remains confidential and may not be
disclosed by the commission except as necessary to further the
investigation unless the agency sharing the information and the
agency receiving the information agree to use of the information by
the receiving agency for enforcement purposes.
(f) The commission and the Texas State Board of Medical
Examiners shall provide information to each other on all
disciplinary actions taken.
(g) The commission and the Texas Board of Chiropractic
Examiners shall provide information to each other on all
disciplinary actions taken.
Added by Acts 2003, 78th Leg., ch. 963, § 4, eff. June 20, 2003.
§ 413.0515. REPORTS OF PHYSICIAN AND CHIROPRACTOR
VIOLATIONS. (a) If the commission or the Texas State Board of
Medical Examiners discovers an act or omission by a physician that
may constitute a felony, a misdemeanor involving moral turpitude, a
violation of state or federal narcotics or controlled substance
law, an offense involving fraud or abuse under the Medicare or
Medicaid program, or a violation of this subtitle, the agency shall
report that act or omission to the other agency.
(b) If the commission or the Texas Board of Chiropractic
Examiners discovers an act or omission by a chiropractor that may
constitute a felony, a misdemeanor involving moral turpitude, a
violation of state or federal narcotics or controlled substance
law, an offense involving fraud or abuse under the Medicare or
Medicaid program, or a violation of this subtitle, the agency shall
report that act or omission to the other agency.
Added by Acts 2003, 78th Leg., ch. 963, § 4, eff. June 20, 2003.
§ 413.052. PRODUCTION OF DOCUMENTS. The commission by
rule shall establish procedures to enable the commission to compel
the production of documents.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.053. STANDARDS OF REPORTING AND BILLING. The
commission by rule shall establish standards of reporting and
billing governing both form and content.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.054. IMMUNITY FROM LIABILITY. (a) A person who
performs services for the commission as a designated doctor, an
independent medical examiner, a doctor performing a medical case
review, or a member of a peer review panel has the same immunity
from liability as a commission member under Section 402.010.
(b) Immunity from liability under this section does not
apply to a person providing medical treatment to an injured
employee.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.055. INTERLOCUTORY ORDERS;
REIMBURSEMENT. (a) The executive director, as provided by
commission rule, may enter an interlocutory order for the payment
of all or part of medical benefits. The order may address accrued
benefits, future benefits, or both accrued benefits and future
benefits.
(b) The subsequent injury fund shall reimburse an insurance
carrier for any overpayments of benefits made under an order
entered under Subsection (a) if the order is reversed or modified by
final arbitration, order, or decision of the commission or a court.
The commission shall adopt rules to provide for a periodic
reimbursement schedule, providing for reimbursement at least
annually.
(c) A party that disputes an order entered under Subsection
(a) is entitled to a hearing. The hearing shall be conducted by the
State Office of Administrative Hearings in the manner provided for
a contested case under Chapter 2001, Government Code. The order is
binding during the pendency of the appeal.
Added by Acts 1999, 76th Leg., ch. 955, § 6, eff. Sept. 1, 1999.
