workers’ compensation medical peer review data call: comprehensive results

11

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.

44

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


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


4% 92% 3% 1%

Retrospective Review of Medical Necessity

40% 8% 19% 34%


<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%


Note 1: Forty-five peer reviews were missing information indicating the “primary reason” they were conducted or the cost of the review.


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 TexasLicensed

Non-TexasLicensed


75%(7,392)

25%(2,523)

Retrospective Review of Medical Necessity 85%(488)

15%(86)


96%(443)

4%(19)

Ability to Return to Work 100%(14)

0%(0)


92%(267)

8%(23)

Other Reasons 99%(175)

1%(2)


Note 1: Five peer reviews were missing information indicating the “primary reason” they were conducted or the licensure of the peer review doctor.


1111

Percentage of Peer Reviews Conducted by Type of Percentage of Peer Reviews Conducted by Type of Doctor and Primary ReasonDoctor and Primary Reason


DC MD/DO PhD Other


10% 85% 5% <1%


8% 91% <1% <1%


2% 97% <1% <1%

Ability to Return to Work 21% 79% 0% 0%


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%


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%


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


Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.


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


Note: “Other” include anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.



Hand Surgery 10%




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


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”






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


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



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



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



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



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



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



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



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



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



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



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



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



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



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



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%


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


Agree AgreePartial

Disagree Nonconclusive


39% 15% 46% 0%


24% 7% 66% 3%


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


Note: Non-TX cases for other reason types are not big enough


Peer Review

Licensure

Peer Review Opinion

Agree Agree Partial

Disagree Nonconclusive


TX 39% 16% 45% 0%

Non TX 39% 11% 50% 0%


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


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%


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


TX 44% 56%

Non TX 46% 54%


TX 56% 44%

Non TX 78% 22%


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


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


Note: “Retrospective Review of Medical Necessity” was the primary reason why peer review is requested.

Peer Review Opinions Peer Review Opinions


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.



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.



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%


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%


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.


Peer Review Doctor ADL StatusPeer Review Doctor ADL Statusas of July 2006as of July 2006

workers’ compensation medical peer review data call: comprehensive results

Documents

cost of peer reviews

data callthese peer

reviews of impairment

texas department of

general data

missing information

primary reasonsource

type of information