New rules proposed by the Texas Department of Insurance Division of Workers’ Compensation will help injured workers in finding and receiving care from a physician, according to the Texas Medical Association.
Among the proposed changes, Texas will boost reimbursement rates to physicians who care for injured workers in non-network situations. Non-network means the employer has chosen not to use managed care for its workers’ compensation insurance, so the injured worker can see any willing physician.
In the proposal, non-network workers’ comp physicians will be paid 140 percent of what Medicare pays for most medical care and 175 percent of Medicare for surgeries. The system previously reimbursed physicians at only 125 percent of Medicare.
The increased rates will make it feasible for more physicians to return to caring for injured workers, the TMA maintained.
The now-defunct Texas Workers’ Compensation Commission slashed physician payments in 2003, forcing physicians who accepted workers’ compensation cases out of the system. Physicians simply could not afford to treat injured workers due to the plunging rates and increasing administrative hassles, the physicians group said. According to a TMA survey, only 26 percent of Texas’ orthopedic surgeons accepted workers’ compensation patients in 2006, a drop from 76 percent in 2002.
“These proposed rules are a big improvement,” said Charlotte Smith, MD, chair of the TMA’s Ad Hoc Committee on Workers’ Compensation. “Now we need to work to ensure more of the employers’ premium dollar for workers’ comp actually goes to patient care.”
Workers’ compensation insurers have a formula that calculates how much of a premium dollar is spent on medical care. In Texas, for most cases, that number is approximately 50 cents.
The top 10 insurers in the Texas workers’ comp system used only 50.6 percent of premiums on health care for injured workers in 2006. That means the insurance companies that insure the vast majority of Texas’ workers’ compensation cases kept almost half of premium dollars employers spent that year. Insurers call the calculation medical loss ratios.
“If I were an employer, I’d be asking why the workers’ compensation system allows insurance companies to pocket 50 cents of every premium dollar. Hard-earned premium dollars should be spent on health care for injured workers, not lining insurers’ pockets,” Dr. Smith noted.
Providing medical care in the workers’ compensation system is different from typical group health insurance. Unique hassles and burdens inherent to the workers’ comp system add cost to physician practices. Ensuring the injury is work-related and determining indemnity benefits (payments to injured workers who miss work) are examples of administrative burdens that do not exist in typical health insurance cases, and they are costly for physicians to manage.
Source: Texas Medical Association, www.texmed.org
Topics Texas Workers' Compensation
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