TDI-DWC Finalized Medical Quality Review Procedure

Dallas, TX (CompNewsNetwork) - On December 14, 2010 the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) solicited and received constructive input from workers' compensation system participants. All comments were carefully considered and discussed. In response, the TDIDWC has made a number of changes and clarifications to the previous draft of the Medical Quality Review Procedure. Workers' Compensation Commissioner Rod Bordelon has approved the revised Medical Quality Review Procedure and the Annual Audit Plan.
All medical quality reviews initiated on or after January 1, 2011 will be performed in accordance with the approved procedure.
Some of the most substantive revisions to the Medical Quality Review Procedure are outlined below:
Quality Assurance Committee (QAC): Reduced the number of members on the panel from five to three. The QAC will only provide a quality check on cases that the nurse investigator has recommended for closure without an Expert review. A majority of the QAC members is needed to overcome the nurse investigator's recommendation to close a complaint with no Expert review. [Sections II(D) and VII(A)]
Additional safeguard to ensure all procedures followed: Added a requirement to perform a quarterly independent audit of selected medical quality reviews completed by the TDI-DWC to insure compliance with the Medical Quality Review Procedure. These quarterly audits will be done in consultation with TDI-DWC's Internal Audit program area. [Section X(D)]
Further Additional safeguards to ensure Plan-Based Audit procedures are followed: Added requirements that each Plan-Based audit procedure will specify the TDI-DWC program area responsible for each specific step in the audit process. [Section IV(4)] Added a requirement that the nurse investigator will verify in writing that the selection of review subjects and case files was done in accordance with the Plan-Based Audit's procedure. [Section V(C)(1)]
Additional procedures for suspected fraud cases: Added a requirement that the Medical Advisor and Enforcement refer suspected fraud cases to the TDI Fraud Unit. [Section VII(C)(5)]
Additional safeguards for conflicts of interest or appearances of impropriety: Added a requirement that Experts and Arbitrators must attest in writing that no known conflicts exist for each subject and individual case file. [Sections V(D)(4) and VII(D)(3)]
Clarification of complaint process: Clarified the complaint process to ensure that only written complaints that are not anonymous will be accepted, and provided more guidance for submission. [Section III(1)]
Clarification of “behavior based” complaints: Clarified that the TDI-DWC is referring to inappropriate non-egregious or unprofessional conduct that is not a standard of care related violation. [(Section III(5)(iv)]
Clarification of procedures to expand the scope of a review: Clarified that Experts must make the recommendation to expand the scope of a review in writing and that the new investigation will start as separate review and will be processed in the same fashion as any other complaint. [Section VI]
Clarification of Experts recommendations: Clarified that Experts will make whatever recommendations are responsive to the specific review questions posed by the Medical Advisor. [Section V(D)(8)]

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