House Bill 7
The Health Care Provider Perspective
| General information | Billing & reimbursement |
| Health care networks | Return-to-work outcomes |
| Consumer report cards | Doctor responsibilities |
| Case management | Preauthorization |
| Additional resources |
Effective September 1, 2005, House Bill 7:
- Abolished the Texas Workers' Compensation Commission (TWCC)
- Transferred most of TWCC's authority to the Texas Department of Insurance (TDI)
- Established the Texas Department of Insurance, Division of Workers' Compensation with a separate, governor-appointed commissioner
- Created the Office of Injured Employee Counsel (OIEC), which will house the ombudsman program formerly handled by TWCC
Implementing the system changes created by House Bill 7 will take several months. We will update our House Bill 7 resource page as needed.
The new law should help reduce your administrative burdens by:
- Reducing the number of disputes
- Expediting treatment approvals
- Encouraging electronic billing and reimbursement
- Promoting appropriate and timely reimbursement and utilization
- Eliminating the state's approved doctor list (by no later than September 1, 2007)
For the time being, insurance carriers will continue to review and pay health care provider (HCP) bills in accordance with DWC rules and guidelines. Future changes related to reimbursement issues will depend on whether the HCP belongs to a workers' compensation health care network. Carriers will reimburse network HCPs in accordance with the network contract and will reimburse non-network HCPs in accordance with the state's fee guidelines.
Insurance carriers must continue to pay, reduce, deny or audit your bill within 45 days after receiving it. Effective September 1, 2005, if a carrier audits a bill, the carrier must complete its bill audit within 160 days, and it must pay 85 percent of the fee guideline (non-network) or contracted (network) amount while the audit is pending. NOTE: This is not a guarantee of 85 percent of the fee or contract amount. The 85 percent rule only applies when carriers audit a bill.
Insurance carriers must notify workers' comp health care network HCPs of their intent to deny a claim's compensability. For network HCPs, the carrier is liable for up to $7,000 of medically necessary health care services prior to the HCP receiving the carrier's notice of denial. In other words, the network HCP is guaranteed some payment for treatment rendered in good faith prior to the carrier's notice of denial. If the carrier successfully contests the claim's compensability, the carrier is not liable for any money after the HCP receives the notice of denial.
Each workers' comp health care network may negotiate its fees, so network HCPs won't have to follow a state-mandated fee schedule. Networks will adopt treatment and RTW guidelines. DWC will also adopt treatment and RTW guidelines for non-network claims.
Additionally, the employee may choose his or her HMO primary provider to be the treating doctor, if the doctor agrees to abide by the workers' comp health care network's treatment and billing requirements. Employees with HMO providers must choose their treating doctor prior to an injury.
NOTE: TWCC rules and forms will remain in effect until new rules and forms supersede them.
The new law no longer specifies which edition of the AMA Guides to use in impairment rating exams. Although the law does not automatically adopt the newest edition, this change in the law allows the commissioner to do so.
All peer review doctors must be licensed in Texas.
Preauthorization
House Bill 7 adds physical and occupational therapy to the list of services that require express preauthorization or concurrent review from insurance carriers. The commissioner of the Texas Department of Insurance, Division of Workers' Compensation adopted an emergency rule to apply to services delivered on or after December 1, 2005.
Additional resources For more information about House Bill 7, click here.