workers' compensation medical peer review data call
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Workers’ Compensation Workers’ Compensation Medical Peer Review Data Call: Medical Peer Review Data Call:
Comprehensive ResultsComprehensive Results
Workers’ Compensation Research Workers’ Compensation Research and Evaluation Groupand Evaluation Group
June 2007June 2007
22
Purpose of Division of WC’s Data CallPurpose of Division of WC’s Data Call
To collect objective information regarding:To collect objective information regarding:
The frequency and cost of peer reviews requested by The frequency and cost of peer reviews requested by insurance carriers;insurance carriers;
The reasons why peer reviews are requested;The reasons why peer reviews are requested;
The types (licensure) of doctors performing peer reviews;The types (licensure) of doctors performing peer reviews;
The opinions of peer review doctors; andThe opinions of peer review doctors; and
The actions taken (or not) by insurance carriers as a result The actions taken (or not) by insurance carriers as a result of the peer review.of the peer review.
33
Summary of Data CallSummary of Data Call Division of Workers’ Compensation (Division) issued data Division of Workers’ Compensation (Division) issued data
call in late July 2006;call in late July 2006;
This is the first time this type of information has been This is the first time this type of information has been collected on WC peer reviews;collected on WC peer reviews;
25 insurance carriers were asked to submit data on every peer 25 insurance carriers were asked to submit data on every peer review they received during September and October 2006;review they received during September and October 2006;
These 25 insurance carriers represented approximately 70% of These 25 insurance carriers represented approximately 70% of the medical payments in 2003; andthe medical payments in 2003; and
Data was submitted to the Division at the end of December Data was submitted to the Division at the end of December
2006.2006.
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General Data Call ResultsGeneral Data Call Results
A total of A total of 11,43711,437 peer reviews received during Sept/Oct 2006 peer reviews received during Sept/Oct 2006 by the 25 insurance carriers included in the data call;by the 25 insurance carriers included in the data call;
These peer reviews were conducted on approximately These peer reviews were conducted on approximately 8,5838,583 WC claims;WC claims;
Approximately Approximately 655 655 doctors (58% Texas licensed/42% non-doctors (58% Texas licensed/42% non-Texas licensed) conducted these reviews.Texas licensed) conducted these reviews.
55
Frequency, Cost and Type of Frequency, Cost and Type of WC Peer Reviews RequestedWC Peer Reviews Requested
66
Percentage of Peer Reviews Conducted by Percentage of Peer Reviews Conducted by Primary ReasonPrimary Reason
Primary Reason Peer Review Was Requested Count Percent
Preauthorization/Concurrent Review of Medical Necessity
9,915 87%
Retrospective Review of Medical Necessity 575 5%
Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis
462 4%
Ability to Return to Work 14 <1%
Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections
290 3%
Other Reasons 178 2%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note 1: Three peer reviews were missing information indicating the “primary reason” they were conducted.
Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.
77
Percentage of Peer Reviews Conducted by Percentage of Peer Reviews Conducted by Cost RangeCost Range
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: Forty-three peer reviews were missing information indicating “cost range”.
Cost RangeCost Range CountCount PercentPercent
<$100<$100 655655 6%6%
$100-250$100-250 9,4199,419 82%82%
$251-500$251-500 597597 5%5%
>$500>$500 723723 6%6%
88
Percentage of Peer Reviews Conducted by Cost Percentage of Peer Reviews Conducted by Cost Range and Primary ReasonRange and Primary Reason
Primary Reason Peer Review Was Requested
<$100 $100-250 $251-500 >$500
Preauthorization/Concurrent Review of Medical Necessity
4% 92% 3% 1%
Retrospective Review of Medical Necessity
40% 8% 19% 34%
Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis
<1% 32% 15% 52%
Ability to Return to Work 0% 50% 7% 43%
Treatment Planning/Appropriateness of Course of Care or Medications /Duration of Care Projections
0% 12% 27% 61%
Other Reasons 0% 71% 19% 10%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note 1: Forty-five peer reviews were missing information indicating the “primary reason” they were conducted or the cost of the review.
Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.
99
Type and Licensure of Doctors Type and Licensure of Doctors Performing Peer ReviewsPerforming Peer Reviews
1010
Percentage of Peer Reviews Conducted by Texas/Non-Texas Percentage of Peer Reviews Conducted by Texas/Non-Texas
Licensed Doctors by Primary ReasonLicensed Doctors by Primary Reason Primary Reason Peer Review Was Requested Texas
LicensedNon-TexasLicensed
Preauthorization/Concurrent Review of Medical Necessity
75%(7,392)
25%(2,523)
Retrospective Review of Medical Necessity 85%(488)
15%(86)
Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis
96%(443)
4%(19)
Ability to Return to Work 100%(14)
0%(0)
Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections
92%(267)
8%(23)
Other Reasons 99%(175)
1%(2)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note 1: Five peer reviews were missing information indicating the “primary reason” they were conducted or the licensure of the peer review doctor.
Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.
1111
Percentage of Peer Reviews Conducted by Type of Percentage of Peer Reviews Conducted by Type of Doctor and Primary ReasonDoctor and Primary Reason
Primary Reason Peer Review Was Requested
DC MD/DO PhD Other
Preauthorization/Concurrent Review of Medical Necessity
10% 85% 5% <1%
Retrospective Review of Medical Necessity
8% 91% <1% <1%
Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis
2% 97% <1% <1%
Ability to Return to Work 21% 79% 0% 0%
Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections
12% 88% 0% <1%
Other Reasons 1% 99% 0% <1%Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note 1: Ten peer reviews were missing information indicating the “primary reason” they were conducted or the type of peer review doctor conducting the review.
Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. “Other providers” include social workers, nurses, nurse practitioners, etc.
1212
Comparison of Peer Review Doctor Type Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewedwith Type of Doctors Being Reviewedpreauthorization/concurrent review of medical necessitypreauthorization/concurrent review of medical necessity
Peer Peer Review Review
Doctor TypeDoctor Type
Type of Doctors Being Reviewed/Type of Treating DoctorType of Doctors Being Reviewed/Type of Treating Doctor
DCDC DODO MDMD OtherOther PhDPhD
DCDC 78%78% 0%0% 21%21% 1%1% 0%0%
DODO 8%8% 11%11% 78%78% 1%1% 1%1%
MDMD 11%11% 6%6% 80%80% 2%2% 2%2%
PhDPhD 18%18% 3%3% 37%37% 9%9% 34%34%
OtherOther 0%0% 4%4% 31%31% 62%62% 4%4%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note : “Other providers” include social workers, nurses, nurse practitioners, etc.
1313
Comparison of Peer Review Doctor Type Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewedwith Type of Doctors Being Reviewed
retrospective review of medical necessityretrospective review of medical necessity
Peer Peer Review Review
Doctor TypeDoctor Type
Type of Doctors Being Reviewed/Type of Treating Type of Doctors Being Reviewed/Type of Treating DoctorDoctor
DCDC DODO MDMD OtherOther
DCDC 85%85% 0%0% 13%13% 2%2%
DODO 20%20% 20%20% 60%60% 0%0%
MDMD 7%7% 3%3% 90%90% 0%0%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note : “Other providers” include social workers, nurses, nurse practitioners, etc.
1414
Specialties of MD/DO Peer Review DoctorsSpecialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Preauthorization/Concurrent Review of
Medical Necessity”
PR Primary Specialty PCT
Orthopedic Surgery 24%
Physical Med. & Rehabilitation 16%
Occupational Medicine 15%
Family Practice 14%
General Surgery 9%
Aerospace Medicine 7%
Anesthesiology 5%
Psychiatry 2%
Administrative Medicine 2%
Hand Surgery 2%
Other 5%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.
1515
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.
PR Primary Specialty PCT
Orthopedic SurgeryOrthopedic Surgery 53%53%
Physical Med. & RehabilitationPhysical Med. & Rehabilitation 28%28%
Hand SurgeryHand Surgery 6%6%
Occupational MedicineOccupational Medicine 2%2%
AnesthesiologyAnesthesiology 2%2%
PsychiatryPsychiatry 2%2%
Family PracticeFamily Practice 1%1%
General SurgeryGeneral Surgery 1%1%
OtherOther 5%5%
Specialties of MD/DO Peer Review DoctorsSpecialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Retrospective Review of Medical Necessity”
1616
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: “Other” include anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.
PR Primary Specialty PCT
Orthopedic Surgery 39%
Hand Surgery 10%
Physical Med. & Rehabilitation 10%
Administrative Medicine 9%
Occupational Medicine 7%
Psychiatry 6%
Family Practice 2%
General Surgery 1%
Other 16%
Specialties of MD/DO Peer Review DoctorsSpecialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Extent of Extent of
Injury/Compensability/Relatedness/Validation of Injured Employee’s Diagnosis”Injury/Compensability/Relatedness/Validation of Injured Employee’s Diagnosis”
1717
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: “Other” include general surgery, anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.
Specialties of MD/DO Peer Review DoctorsSpecialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Ability to Return to Work”, “Treatment Ability to Return to Work”, “Treatment
Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections”, or Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections”, or “Other Claim Management Actions”“Other Claim Management Actions”
PR Primary Specialty PCT
Orthopedic Surgery 33%
Occupational Medicine 22%
Physical Med. & Rehabilitation 17%
Administrative Medicine 5%
Psychiatry 2%
Family Practice 1%
Hand Surgery 1%
Anesthesiology 1%
Other 18%
1818
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being ReviewedSpecialties of Doctors Being Reviewed
PR primary specialty HCP primary specialty Count Percentage
administrative medicine anesthesiology 11 7%
administrative medicine family practice 17 11%
administrative medicine general practice 5 3%
administrative medicine general surgery 1 1%
administrative medicine hand surgery 2 1%
administrative medicine internal medicine 6 4%
administrative medicine neurological surgery 11 7%
administrative medicine neurology 1 1%
administrative medicine occupational medicine 2 1%
administrative medicine ophthalmology 1 1%
administrative medicine orthopedic surgery 83 54%
administrative medicine other specialty 2 1%
administrative medicine pediatrics 1 1%
administrative medicine physical med. & rehabilitation 4 3%
administrative medicine plastic surgery 1 1%
administrative medicine psychiatry 2 1%
administrative medicine unspecified 4 3%
1919
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
aerospace medicine anesthesiology 18 9%
aerospace medicine anesthesiology - pain management 1 1%
aerospace medicine family practice 26 13%
aerospace medicine general practice 9 5%
aerospace medicine general surgery 2 1%
aerospace medicine hand surgery 3 2%
aerospace medicine internal medicine 10 5%
aerospace medicine neurological surgery 6 3%
aerospace medicine neurology 3 2%
aerospace medicine obstetrics and gynecology 1 1%
aerospace medicine occupational medicine 9 5%
aerospace medicine orthopedic surgery 88 45%
aerospace medicine other specialty 4 2%
aerospace medicine physical med. & rehabilitation 12 6%
aerospace medicine plastic surgery 2 1%
aerospace medicine psychiatry 2 1%
aerospace medicine unspecified 1 1%
2020
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
anesthesiology anesthesiology 127 46%
anesthesiology dermatology 1 0%
anesthesiology emergency medicine 2 1%
anesthesiology family practice 17 6%
anesthesiology general practice 4 1%
anesthesiology hand surgery 2 1%
anesthesiology internal medicine 3 1%
anesthesiology manipulative therapy 1 0%
anesthesiology neurological surgery 5 2%
anesthesiology neurology 4 1%
anesthesiology obstetrics and gynecology 1 0%
anesthesiology occupational medicine 4 1%
anesthesiology orthopedic surgery 42 15%
anesthesiology other specialty 10 4%
anesthesiology pediatric endocrinology 1 0%
anesthesiology pediatrics 1 0%
anesthesiology physical med. & rehabilitation 31 11%
anesthesiology plastic surgery 1 0%
anesthesiology psychiatry 7 3%
anesthesiology public health 2 1%
anesthesiology unspecified 12 4%
2121
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
cardiovascular diseases anesthesiology 1 17%
cardiovascular diseases cardiovascular diseases 3 50%
cardiovascular diseases family practice 1 17%
cardiovascular diseases orthopedic surgery 1 17%
diagnostic radiology family practice 4 36%
diagnostic radiology occupational medicine 2 18%
diagnostic radiology orthopedic surgery 5 45%
emergency medicine family practice 5 19%
emergency medicine general surgery 2 8%
emergency medicine hand surgery 1 4%
emergency medicine internal medicine 1 4%
emergency medicine occupational medicine 2 8%
emergency medicine orthopedic surgery 11 42%
emergency medicine other specialty 1 4%
emergency medicine pediatrics 1 4%
emergency medicine physical med. & rehabilitation 2 8%
2222
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
family practice aerospace medicine 1 2%
family practice anesthesiology 2 4%
family practice emergency medicine 1 2%
family practice family practice 12 26%
family practice general practice 1 2%
family practice general surgery 1 2%
family practice internal medicine 4 9%
family practice neurological surgery 1 2%
family practice occupational medicine 1 2%
family practice orthopedic surgery 19 40%
family practice physical med. & rehabilitation 2 4%
family practice plastic surgery 1 2%
family practice psychiatry 1 2%
gastroenterology anesthesiology 1 100%
2323
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
general practice family practice 4 20%
general practice neurological surgery 1 5%
general practice obstetrics and gynecology 1 5%
general practice orthopedic surgery 13 65%
general practice physical med. & rehabilitation 1 5%
2424
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
general surgery anesthesiology 58 16%
general surgery anesthesiology - pain management 1 0%
general surgery emergency medicine 1 0%
general surgery family practice 58 16%
general surgery gastroenterology 1 0%
general surgery general practice 17 5%
general surgery general surgery 5 1%
general surgery hand surgery 2 1%
general surgery internal medicine 8 2%
general surgery manipulative therapy 1 0%
general surgery neurological surgery 10 3%
general surgery neurology 1 0%
general surgery occupational medicine 16 4%
general surgery ophthalmology 3 1%
general surgery orthopedic surgery 139 38%
general surgery other specialty 5 1%
general surgery otolaryngology 3 1%
general surgery pain management 1 0%
general surgery physical med. & rehabilitation 35 9%
general surgery plastic surgery 2 1%
general surgery psychiatry 2 1%
general surgery unspecified 1 0%
2525
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
hand surgery aerospace medicine 1 1%
hand surgery anesthesiology 3 3%
hand surgery family practice 15 16%
hand surgery general practice 3 3%
hand surgery general surgery 2 2%
hand surgery hand surgery 14 15%
hand surgery internal medicine 2 2%
hand surgery neurological surgery 1 1%
hand surgery neurology 1 1%
hand surgery occupational medicine 3 3%
hand surgery orthopedic surgery 37 39%
hand surgery plastic surgery 12 13%
hand surgery unspecified 1 1%
infectious diseases family practice 1 100%
2626
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
internal medicine allergy 1 2%
internal medicine anesthesiology 4 6%
internal medicine emergency medicine 1 2%
internal medicine family practice 10 16%
internal medicine general practice 7 11%
internal medicine general surgery 2 3%
internal medicine internal medicine 12 19%
internal medicine neurological surgery 4 6%
internal medicine occupational medicine 4 6%
internal medicine ophthalmology 1 2%
internal medicine orthopedic surgery 8 13%
internal medicine physical med. & rehabilitation 6 10%
internal medicine plastic surgery 1 2%
internal medicine psychiatry 1 2%
neonatal-prenatal medicine family practice 1 100%
2727
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
neurological surgery anesthesiology 2 5%
neurological surgery family practice 1 2%
neurological surgery general practice 2 5%
neurological surgery internal medicine 1 2%
neurological surgery neurological surgery 21 50%
neurological surgery neurology 1 2%
neurological surgery orthopedic surgery 11 26%
neurological surgery physical med. & rehabilitation 1 2%
neurological surgery plastic surgery 1 2%
neurological surgery vascular surgery 1 2%
neurology anesthesiology 1 5%
neurology family practice 7 32%
neurology general practice 1 5%
neurology internal medicine 2 9%
neurology neurological surgery 1 5%
neurology neurology 5 23%
neurology oncology 1 5%
neurology orthopedic surgery 2 9%
neurology pediatrics 2 9%
2828
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
occupational medicine anesthesiology 50 15%
occupational medicine anesthesiology - pain management 1 0%
occupational medicine cardiovascular diseases 1 0%
occupational medicine dermatology 1 0%
occupational medicine diagnostic radiology 1 0%
occupational medicine emergency medicine 4 1%
occupational medicine family practice 64 19%
occupational medicine general practice 12 4%
occupational medicine general surgery 7 2%
occupational medicine hand surgery 3 1%
occupational medicine internal medicine 12 4%
occupational medicine neurological surgery 12 4%
occupational medicine neurology 3 1%
occupational medicine occupational medicine 13 4%
occupational medicine orthopedic surgery 120 35%
occupational medicine other specialty 3 1%
2929
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
occupational medicine pathology 2 1%
occupational medicine pediatrics 1 0%
occupational medicine physical med. & rehabilitation 16 5%
occupational medicine plastic surgery 1 0%
occupational medicine psychiatry 3 1%
occupational medicine radiology 3 1%
occupational medicine unspecified 3 1%
occupational medicine urology 3 1%
ophthalmology family practice 1 20%
ophthalmology occupational medicine 2 40%
ophthalmology ophthalmology 1 20%
ophthalmology psychiatry 1 20%
3030
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
orthopedic surgery allergy and immunology 2 0%
orthopedic surgery anesthesiology 65 5%
orthopedic surgery cardiovascular surgery 6 0%
orthopedic surgery dermatology 3 0%
orthopedic surgery diagnostic radiology 1 0%
orthopedic surgery emergency medicine 8 1%
orthopedic surgery family medicine 1 0%
orthopedic surgery family practice 96 8%
orthopedic surgery gastroenterology 1 0%
orthopedic surgery general practice 27 2%
orthopedic surgery general surgery 11 1%
orthopedic surgery hand surgery 9 1%
orthopedic surgery infectious diseases 1 0%
orthopedic surgery internal medicine 30 2%
orthopedic surgery neurological surgery 93 8%
orthopedic surgery neurology 16 1%
orthopedic surgery obstetrics and gynecology 3 0%
orthopedic surgery occupational medicine 20 2%
orthopedic surgery ophthalmology 4 0%
orthopedic surgery orthopedic surgery 719 59%
orthopedic surgery other specialty 15 1%
3131
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
orthopedic surgery pediatrics 4 0%
orthopedic surgery physical med. & rehabilitation 41 3%
orthopedic surgery plastic surgery 15 1%
orthopedic surgery psychiatry 5 0%
orthopedic surgery radiology 2 0%
orthopedic surgery rheumatology 1 0%
orthopedic surgery unspecified 10 1%
orthopedic surgery urology 2 0%
otolaryngology orthopedic surgery 3 100%
pathology orthopedic surgery 1 100%
pediatrics general surgery 1 33%
pediatrics orthopedic surgery 1 33%
pediatrics urology 1 33%
3232
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
physical med. & rehabilitation aerospace medicine 1 0%
physical med. & rehabilitation anesthesiology 93 23%
physical med. & rehabilitation emergency medicine 4 1%
physical med. & rehabilitation family practice 61 15%
physical med. & rehabilitation general practice 7 2%
physical med. & rehabilitation general surgery 4 1%
physical med. & rehabilitation gynecology 1 0%
physical med. & rehabilitation hand surgery 1 0%
physical med. & rehabilitation internal medicine 14 3%
physical med. & rehabilitation neurological surgery 19 5%
physical med. & rehabilitation neurology 4 1%
physical med. & rehabilitation occupational medicine 21 5%
physical med. & rehabilitation orthopedic surgery 95 24%
physical med. & rehabilitation other specialty 10 2%
physical med. & rehabilitation pathology 1 0%
physical med. & rehabilitation physical med. & rehabilitation 49 12%
physical med. & rehabilitation plastic surgery 3 1%
physical med. & rehabilitation psychiatry 6 1%
physical med. & rehabilitation radiology 2 0%
physical med. & rehabilitation unspecified 7 2%
3333
Comparison of Peer Review Doctor Specialties with Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’dSpecialties of Doctors Being Reviewed, Cont’d
PR primary specialty HCP primary specialty Count Percentage
plastic surgery family practice 1 33%
plastic surgery orthopedic surgery 1 33%
plastic surgery plastic surgery 1 33%
psychiatry anesthesiology 13 20%
psychiatry family practice 8 12%
psychiatry general practice 3 5%
psychiatry internal medicine 2 3%
psychiatry neurological surgery 1 2%
psychiatry neurology 2 3%
psychiatry orthopedic surgery 7 11%
psychiatry physical med. & rehabilitation 6 9%
psychiatry psychiatry 16 25%
psychiatry unspecified 6 9%
psychiatry vascular surgery 1 2%
radiology internal medicine 1 100%
urology occupational medicine 1 100%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
3434
Peer Review Opinions and Carrier Peer Review Opinions and Carrier ActionsActions
3535
Peer Review Opinions by Primary Reason Peer Peer Review Opinions by Primary Reason Peer Review Was RequestedReview Was Requested
Primary Reason Peer Review Was Requested
Agree AgreePartial
Disagree Nonconclusive
Preauthorization/Concurrent Review of Medical Necessity
39% 15% 46% 0%
Retrospective Review of Medical Necessity
24% 7% 66% 3%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
3636
Peer Review Opinions by Primary Reason Peer Peer Review Opinions by Primary Reason Peer Review Was Requested and Texas/Non-Texas Review Was Requested and Texas/Non-Texas
LicensureLicensure
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: Non-TX cases for other reason types are not big enough
Primary Reason Peer Review Was Requested
Peer Review
Licensure
Peer Review Opinion
Agree Agree Partial
Disagree Nonconclusive
Preauthorization/Concurrent Review of Medical Necessity
TX 39% 16% 45% 0%
Non TX 39% 11% 50% 0%
Retrospective Review of Medical Necessity
TX 27% 7% 63% 4%
Non TX 14% 7% 79% 0%
3737
Peer Review Opinions by Primary Reason Peer Peer Review Opinions by Primary Reason Peer Review Was Requested Cont’dReview Was Requested Cont’d
Primary Reason Peer Review Was Requested
Agree Disagree Nonconclusive
Extent of Injury/Compensability Extent of Injury/Compensability /Relatedness/Validation of Injured /Relatedness/Validation of Injured Employee's DiagnosisEmployee's Diagnosis
27% 69% 4%
Treatment Planning/Appropriateness Treatment Planning/Appropriateness of Course of Care or Medications of Course of Care or Medications /Duration of Care Projections/Duration of Care Projections
31% 69% 0%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note1: If “ability to return to work” was one of the reasons PR were requested, peer review doctors provided an opinion regarding return to work status for 62% of those cases.
Note2: Peer review opinions for other primary reasons were not included because too few peer reviews reported on individual issues.
3838
Carrier Actions as a Result of Peer Reviews Carrier Actions as a Result of Peer Reviews ConductedConducted
Overall, approximately Overall, approximately 45%45% of all peer reviews reported in the of all peer reviews reported in the data call resulted in some sort of adverse action taken by the data call resulted in some sort of adverse action taken by the insurance carrier (e.g., denial of medical necessity, denial of insurance carrier (e.g., denial of medical necessity, denial of claim, denial of benefits).claim, denial of benefits).
Approximately Approximately 44%44% of all peer reviews conducted by Texas of all peer reviews conducted by Texas licensed doctors resulted in some sort of adverse action taken licensed doctors resulted in some sort of adverse action taken by the insurance carrier.by the insurance carrier.
Approximately Approximately 47%47% of all peer reviews conducted by non- of all peer reviews conducted by non-Texas licensed doctors resulted in some sort of adverse action Texas licensed doctors resulted in some sort of adverse action taken by the insurance carrier.taken by the insurance carrier.
3939
Percentage of Medical Necessity Peer Reviews Percentage of Medical Necessity Peer Reviews that Resulted in an Adverse Carrier Action by that Resulted in an Adverse Carrier Action by
Texas/Non-Texas LicensureTexas/Non-Texas LicensurePrimary Reason Peer Review Was
RequestedPeer Review
LicensureCarrier Action
AdverseAction
No AdverseAction
Preauthorization/Concurrent Review of Medical Necessity
TX 44% 56%
Non TX 46% 54%
Retrospective Review of Medical Necessity
TX 56% 44%
Non TX 78% 22%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
4040
Carrier Actions Compared to Peer Review Opinions Carrier Actions Compared to Peer Review Opinions on Preauthorization/Concurrent Review of Medical on Preauthorization/Concurrent Review of Medical
NecessityNecessity
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: “Preauthorization/concurrent Review of Medical Necessity” was the primary reason why peer review is requested.
Peer Review Doctor’s Peer Review Doctor’s OpinionOpinion
Carrier ActionsCarrier Actions
Approved Preauth/ Approved Preauth/ Concurrent ReviewConcurrent Review
Approved Modified Approved Modified Preauth/ Concurrent Preauth/ Concurrent
ReviewReview
Denied Preauth/ Denied Preauth/ Concurrent ReviewConcurrent Review
Agreed with Medical Agreed with Medical NecessityNecessity 96%96% 3%3% 1%1%
Disagreed with Medical Disagreed with Medical Necessity Necessity 2%2% 1%1% 97%97%
Partially Agreed with Partially Agreed with Medical NecessityMedical Necessity 7%7% 91%91% 2%2%
4141
Carrier Actions Compared to Peer Review Carrier Actions Compared to Peer Review Opinions on Retrospective Review of Opinions on Retrospective Review of
Medical NecessityMedical Necessity
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Note: “Retrospective Review of Medical Necessity” was the primary reason why peer review is requested.
Peer Review Opinions Peer Review Opinions
Carrier ActionsCarrier Actions
Carrier Approved Carrier Approved Payment Payment
Carrier Approved Carrier Approved Partial Payment Partial Payment
Carrier Denied Carrier Denied PaymentPayment
Agreed with Medical Agreed with Medical NecessityNecessity 69%69% 7%7% 24%24%
Disagreed with Medical Disagreed with Medical Necessity Necessity 2%2% 1%1% 97%97%
Partially Agreed with Partially Agreed with Medical NecessityMedical Necessity 4%4% 70%70% 26%26%
4242
Carrier Actions Compared to Peer Review Opinions Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatednesson Extent of Injury/Compensability/Relatedness
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.Note: “Extent of Injury/compensability/relatedness/validation of injured employee’s diagnosis” was the primary reason why peer review is requested. Analysis for other primary reasons were excluded because too few peer reviews reported on individual issues.
Peer Review Opinions Peer Review Opinions
Carrier ActionsCarrier Actions
Carrier Disputed Extent of Carrier Disputed Extent of Injury/Compensability/ Injury/Compensability/
RelatednessRelatedness
Carrier Did Not Dispute Extent Carrier Did Not Dispute Extent of Injury/Compensability/ of Injury/Compensability/
RelatednessRelatedness
Agreed that Injury or Agreed that Injury or Diagnosis Was Related to the Diagnosis Was Related to the Compensable InjuryCompensable Injury 13%13% 87%87%
Disagreed that Injury or Disagreed that Injury or Diagnosis Was Related to the Diagnosis Was Related to the Compensable InjuryCompensable Injury 43%43% 57%57%
Opinion Non-ConclusiveOpinion Non-Conclusive 8%8% 92%92%
4343
Carrier Actions Compared to Peer Review Carrier Actions Compared to Peer Review Opinions on Extent of Opinions on Extent of
Injury/Compensability/RelatednessInjury/Compensability/Relatedness
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.Note: “Extent of Injury/compensability/relatedness/validation of injured employee’s diagnosis” was the primary reason why peer review is requested.
Peer Review Opinions Peer Review Opinions
Carrier ActionsCarrier Actions
Carrier Denied claimCarrier Denied claim Carrier Did Not Deny ClaimCarrier Did Not Deny Claim
Agreed that Injury or Diagnosis Agreed that Injury or Diagnosis Was Related to the Was Related to the Compensable InjuryCompensable Injury 2%2% 98%98%
Disagreed that Injury or Disagreed that Injury or Diagnosis Was Related to the Diagnosis Was Related to the Compensable InjuryCompensable Injury 21%21% 79%79%
Opinion Non-ConclusiveOpinion Non-Conclusive 4%4% 96%96%
4444
Information on the Types of Information on the Types of Claims Being ReviewedClaims Being Reviewed
4545
Average Claim Maturity of Claims Being Average Claim Maturity of Claims Being Reviewed During the Data CallReviewed During the Data Call
Timeframe from the injury date to the date being reviewed Count Percentage
Less than 1 month 533 6%
1 to 2 months 729 9%
2 to 3 months 569 7%
3 to 6 months 1,445 17%
6 to 12 months 1,534 18%
12 to 24 months 1,605 19%
24+ months 2,168 25%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
4646
Peer Review Volume Per Claim in the Peer Review Volume Per Claim in the Data Call PeriodData Call Period
# of Peer Reviews Per claim Count Percent
1 6504 76%
2 1529 18%
3 382 5%
4 135 2%
>= 5 33 <1%
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
4747
Approved Doctor List (ADL) Approved Doctor List (ADL) Status of Peer Review DoctorsStatus of Peer Review Doctors
4848
Section 408.023 (b) (3), Labor Code, requires all doctors who perform Section 408.023 (b) (3), Labor Code, requires all doctors who perform medical peer review in the Texas workers’ compensation system to be medical peer review in the Texas workers’ compensation system to be on the Division’s Approved Doctor List (ADL).on the Division’s Approved Doctor List (ADL).
359 (55 percent) of the 655 peer review doctors were on the Approved 359 (55 percent) of the 655 peer review doctors were on the Approved Doctor List (ADL) as of July 2006. Doctor List (ADL) as of July 2006.
About 20 (6 percent) of the 359 peer review doctors practicing with a About 20 (6 percent) of the 359 peer review doctors practicing with a temporary ADL Exception as of July 2006.temporary ADL Exception as of July 2006.
8,600 (75 percent) of the 11,437 peer reviews were conducted by the 8,600 (75 percent) of the 11,437 peer reviews were conducted by the ADL doctors.ADL doctors.
516 of the 8,600 peer reviews were conducted by doctors practicing 516 of the 8,600 peer reviews were conducted by doctors practicing with a temporary ADL exception as of July 2006.with a temporary ADL exception as of July 2006.
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.
Peer Review Doctor ADL StatusPeer Review Doctor ADL Statusas of July 2006as of July 2006
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