Texas Sunset Commission

Texas Sunset Commission

 The Sunset Commission has considered, modified, and voted on the Sunset staff recommendations.  Please refer to previous Downs Stanford Advisories regarding the Sunset staff report.  The following is a summary of the recommended changes:

All medical necessity disputes, regardless of dollar amount, will be considered by the Division of Workers’ Compensation (DWC).  Medical fee disputes, regardless of dollar amount, will be resolved by SOAH. 

The Appeals Panel will have the authority to affirm the CCH Decision and Order without agreeing to the facts of the case. As a result, the Appeals Panel may disagree with the Findings of Fact but nevertheless affirm the decision. 

The Sunset Commission also noted many of HB 7 changes are just being implemented.  Moreover, due to the unique structure of the Department and the Division, another Sunset review will be necessary in six years and DWC review should be independent of the Texas Department of Insurance (TDI). 

The Sunset Commission also removed language extending the timeframe to appeal decisions regarding medical necessity and medical fee disputes to district court.  They also removed venue changes for appeals of medical disputes. 

The Commission abolished recommendations creating a certification fee payable by designated doctors and removing designated doctor’s scheduling data from its website.  The designated doctor matrix would be changed to select designated doctors based on diagnosis and injury instead of treatment.  It is unclear if this will lead to an increase in the number of chiropractors serving as designated doctors.  Designated doctors would also be allowed to participate in any county rather than the current twenty county limit.

Senator Hegar proposed moving monies collected by DWC for monetary penalties to the general revenue account. 

Mr. McMahen, one of the DWC public members, noted hearing officers have a maximum work load of two hundred (200) cases but current workload averages are about one hundred thirty five (135).  He recommended reducing staff to achieve efficiency. 

Representative Anchia proposed DWC insure by rule certain limitations on ex parte communications regarding any decision in enforcement actions in which the Commissioner retains ultimate authority. 

The most anticipated changes concerned quality of medical care.  Recent allegations combined with Sunset staff’s proposed changes have created a political and media backlash.  As a result, Representative Anchia and Senator Hegar re-drafted Sunset staff proposals.  All staff recommendations were severed and replaced with recommendations found in the attached document.  Among the suggested recommendations were:

Change in statute

·        2.1 requires the Division to develop and strengthen medical review guidelines to handle both complaint-based and audit-based reviews. 

·        2.2 establishes by statute the Quality Assurance Panel (QAP) to assist the Medical Advisor and Medical Quality Review Panel to provide a second level evaluation for all reviews. 

Management action

·        2.3 clarifies the QAP should be selected from a pool of appointed MQRP members from diverse healthcare specialty backgrounds with expertise in utilization review and quality assurance.

·        The Division should also create procedures outlining the time frame a member may serve on the QAP; communications with QAP members on enforcement outcomes; and clarify the roles and responsibilities of QAP members at staff meetings. 

Change in statute

·        2.4 requires the Commissioner to create rules, with input from the Medical Advisor, and create prerequisites to serve as an MQRP expert review or using the Texas Medical Board’s expert review process as a guide. 

·        The Division should outline rules and regulations governing length of service, training, grounds for removal, treatment and return to work guidelines, and other evidence based medicine resources. 

·        2.5 requires the Division to work with licensing boards to expand the pool of medical quality review panel members in consultation with the Medical Advisor.  In such circumstances, the Division should develop a method to partner with other agencies to access outside experience on an as needed basis.

Additional changes can certainly be expected to occur when the legislature meets in 2011. 

The Sunset Commission voted to review OIEC at the same time as DWC, independent of TDI, in six years as opposed to twelve. 

Click here to read Sunset Commission's recommendations