Winter 2005

Health Care Network Option Coming Soon
By Jeremiah Bentley, Public Affairs Analyst

Texas Mutual Insurance Company is preparing for the 2006 launch of its workers’ compensation health care network option. Employers who participate in the network will earn a premium discount, regardless of the renewal date on their policy.

All networks must apply for certification by the Texas Department of Insurance (TDI). Under the law, an insurance carrier may not offer a policy with network coverage until the network has been certified by TDI. TDI will begin accepting applications for certification in January 2006, and it will have 60 days to approve or deny each completed application.

Texas Mutual Insurance Company is in the final stages of selecting its network partner and determining the premium discount. Employers who have operations in a network service area will receive more information from their agents and Texas Mutual Insurance Company over the next few months.

“In the meantime, we will start telling our customers how the network system will work,” said Texas Mutual^® President Russ Oliver. “We think many of our policyholders will want to start taking advantage of this exciting new benefit of Texas Mutual^® coverage as soon as TDI certifies our network partner.”

House Bill 7 and networks
Health care costs in the Texas workers’ compensation system are among the highest in the nation. Furthermore, studies suggest that one out of every four injured employees does not return to work.

In an effort to improve the system, the Legislature passed House Bill 7 this spring. The bill will usher in the most sweeping changes the Texas workers’ compensation system has seen in over a decade.

One high-profile provision of House Bill 7 allows insurance carriers to establish or contract with health care networks. Networks should help control health care costs in the system, and thereby reduce premiums.

“The Legislature took a bold step in opening the door for networks in the workers’ comp system,” said Lisa Corless, Texas Mutual^® senior vice president of claim operations. “Now it’s time for carriers and employers to take the lead. Texas Mutual will be ready to go as soon as TDI approves our partner’s network application.”

Why choose network coverage?
Employers who take advantage of the network option will enjoy benefits beyond the premium discount. House Bill 7 provides for a new model of health care in the Texas workers’ compensation system. The primary goal of the network system is to return injured employees to work as soon as medically reasonable.

This renewed emphasis on return-to-work is good for employers and employees. Studies show that injured employees who go back to work actually recover faster. Early return-to-work also minimizes the effects of paying overtime, hiring extra help, and other costs associated with workplace accidents.

The new law requires health care providers to be versed in occupational medicine. Health care providers must rely on evidence-based treatment and return-to-work guidelines adopted by networks in delivering care. Additionally, networks must have quality improvement programs that include case management to identify injured workers who need extra attention.

To help ensure that the new system achieves its goals, House Bill 7 requires TDI to produce “consumer report cards” that measure such things as the networks’ return-to-work outcomes, access to care, health care costs, and utilization. The bill also requires the Department of Assistive and Rehabilitative Services to help injured workers who need to be retrained before they can re-enter the workforce.

For the new system to be effective, however, employers must play an important role. If injured workers cannot perform all of their original job duties, their treating doctor may release them to return to work under modified duty. Employers should work with providers and Texas Mutual Insurance Company to identify modified-duty assignments and accommodate injured employees’ work restrictions.

“Getting injured workers back on the job should be the common goal of everyone involved in our workers’ compensation system,” said Corless. “If all stakeholders commit to the process, we will realize the full benefits of this new system.”

Employers’ network responsibilities
Network participation comes with responsibilities. If employers do not fulfill their responsibilities, the network provisions will not take effect.

When employers select the network option, they must give all current employees a notice of network requirements. They must also give the notice to new employees and to all employees who are injured on the job.

The notice must be in English, Spanish and any other language common to employees. It must include a list of network providers, a notice that the employee must see a treating doctor that is in the network, an explanation of the complaint process, and other information the employee needs to receive care within the network.

Employers must have each employee sign a form acknowledging receipt of the notice, and employers must establish a standardized process for delivering the notice. If an employee refuses to sign the acknowledgment, he or she will still be required to comply with the terms of the network if the employer maintains a record of delivery.

Texas Mutual Insurance Company and its network partner will provide the forms and information employers need to properly notify employees of their network responsibilities.

Employees’ network responsibilities
Employees have network responsibilities, too. If they do not fulfill their responsibilities, they may be responsible for paying for their own health care.

Injured workers who have received the notice as required by the law and who live within the network’s service area must receive care from a network treating doctor. Employees who are not satisfied with their initial choice of treating doctor may change the treating doctor within the network one time. After that, the network must approve treating doctor changes.

In certain situations, employees may seek care outside the network. An employee who has a pre-existing relationship with an HMO doctor may receive treatment for a workers’ compensation injury from that provider. The provider must agree to the terms and provisions of the network in order for this exception to take effect. An employee may also go outside of the network for emergency care or to receive treatment from a specialist referred by the network treating doctor.

More to come
Texas Mutual Insurance Company will work with agents to offer the network option to employers as soon as possible after its network partner receives TDI certification. Employers can contact their agent or visit www.texasmutual.com/employers/networkph.shtm for more information on health care networks.

COMPNEWS - WINTER 2005
Health Care Network Option Coming Soon
Five Reasons You Should Report Every Workplace Injury
Cleaning Up Workplace Substance Abuse
President's Message
You Need to Know
Fraud Corner

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