Texas workers’ comp agency cited for serious flaws in state audit report
[Continued from: South Carolina’s workers’ comp agency has more problems than delayed deposits of fines]
Besides the problems revealed by a state agency’s audit of the South Carolina workers’ comp system, a similar audit has revealed problems in the Texas worker’s comp system.
According to a Nov. 24 account at The Lone Star Report, the bottom line is that the problems revealed in the report by the State Auditor’s Office (TSAO)is that Texas employers who pay for workers’ comp insurance may be subsidizing a system that pays for unnecessary treatments, thereby siphoning off money that could be used to create more jobs:
On this the day before Thanksgiving, the State Auditor’s Office has dropped a highly critical report on the Texas Department of Insurance’s Division of Workers’ Compensation. The report finds that the division maintains unreliable information and has weaknesses in complaint processing, the medical quality review process, and the enforcement and sanction process.
Those problems increase the risk of injured workers receiving unnecessary medical procedures and overutilization within the workers’ compensation system, the report finds. In other words, Texas employers that pay for the workers’ compensation system are at risk of paying for a lot of unnecessary stuff, which will hinder their ability to keep Texas creating more jobs.
Auditors unable to determine appropriate disciplinary action
However, another Nov. 24 report, in the Fort Worth Star-Telegram, says the audit reveals a system so shoddy that “that auditors couldn’t determine whether the department took appropriate disciplinary action for providers that committed violations.”
The Star-Telegram report does point out that “overutilization” may be a result but also outlines findings of pervasive “weaknesses in enforcement, information reliability, medical quality review and complaint processing.”
To be sure, the warning about the potential for “unnecessary procedures” and “overutilization” derives straight from the opening section of TSAO’s summary of the report, entitled “An Audit Report on Medical Quality Reviews at the Division of Workers’ Compensation within the Texas Department of Insurance”:
Overall Conclusion
Significant process and information issues at the Division of Workers’ Compensation (DWC) within the Texas Department of Insurance (TDI) significantly inhibit DWC’s ability to monitor the quality of health care in the workers’ compensation system. The issues are in four primary areas:
- Unreliable information.
- Weaknesses in complaint processing.
- Weaknesses in the medical quality review process.
- Weaknesses in the enforcement and sanction process.
These issues increase the risk of (1) injured workers receiving unnecessary medical procedures and (2) overutilization within the workers’ compensation system.
Carriers not part of the audit
However, one wonders about the potential for under-served injured workers, too. With all these weakness being identified, what about enforcement actions and sanctions involving carriers that deny treatments or even entire claims? We’ve covered previous hearings and audits that found problems with enforcement cases, employer actions, and incomplete case logs and reviews.
Another question arises: who’s reporting unnecessary medical procedures? After all, how many injured people are likely to resent too much care or treatment?
However, as the title indicates, the focus of this report is the medical review process. As such, it is described as “Phase II” of the audit; the Phase I audit report can be found here.
Two different systems
Commenting on the DWC’s failure to maintain “complete information,” the TSAO report found that until January 2010, the agency “recorded complaints that the Office of the Medical Advisor investigated related to workers’ compensation providers in two different systems, neither of which contained complete or accurate information.” Furthermore, the agency is inconsistent in tracking medical quality reviews and enforcement actions, “and neither system contains complete or accurate information.”
Inconsistent information
The conclusion to that section suggests the possibility Texas workers’ comp medical providers may receive inconsistent information from the state:
The extent and significance of the incomplete information impaired the State Auditor’s Office’s ability to form a conclusion on the audit objective to determine whether TDI issues appropriate and consistent disciplinary orders for workers’ compensation providers that have committed violations or are identified as noncompliant. TDI and DWC will need to implement significant corrective action to establish and maintain complete and reliable complaint and medical quality review information necessary to carry out their responsibilities.
Agency agreed with all recommendations
Of 21 specific recommendations made by TSAO in five separate areas of concerns, the workers’ comp agency agreed with each of TSAO’s recommended changes.
As part of its conclusion, in the Appendices, TSAO wrote:
The State Auditor’s Office determined that the information DWC maintains on its reviews of workers’ compensation cases in its Tracker system was not reliable for the purposes of making a conclusion on the audit objective to determine whether TDI issues appropriate and consistent disciplinary orders for workers’ compensation providers and carriers that have committed violations or are identified as noncompliant. To assess the reliability of the case review information in the Tracker system, auditors conducted interviews with DWC staff and performed analysis on and observed fields within the Tracker system. The results of those tests indicated that information in the Tracker system was not reliable. DWC does not update that system consistently, and it does not enter information into that system for all medical quality reviews.
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Frequently enough, a worker’s compensation case may be so complex as to demand legal representation. However, sometimes what seems like a cut-and-dried situation to an injured worker may result in a smaller award than envisioned–or even a denial. Have you, a friend or a loved one been injured on the job? Whether you’re merely seeking answers about your rights or believe a lawsuit may be necessary, be sure to seek counsel with attorneys trained and experienced in workers’ compensation. Here’s some resources:
