TWCC Audits Carriers for Handling of Medical Bills

The Texas Workers’ Compensation Commission announced it recently completed audits of several insurance carriers for compliance with preauthorization processing requirements and for performance on retrospective review of medical bills for preauthorized services for injured workers.

The audits conducted by the Commission’s Compliance and Practices Division showed that only one of the audited carriers met or exceeded the compliance standard for processing preauthorization requests. Two carriers met or exceeded the compliance standard for appropriateness of denials and reductions of preauthorized services.

Penalties totaling $399,090 were issued to seven carriers as a result of the recent audits.

“The Commission had received a growing number of complaints from health care providers that preauthorized bills were not being paid by insurance carriers,” said Robert L. Shipe, executive director of the Commission. “The Compliance and Practices Division initiated audits to explore the issue.”

Shipe said Commission rules require 95 percent compliance with audit standards. However, the Commission encourages all system participants to strive for 100 percent compliance. On average, the carriers had 86.4 percent compliance with preauthorization processing requirements and 91.9 percent compliance with the standards for reviewing medical bills related to the preauthorized services.

Further information regarding audits and compliance may be obtained by contacting the Commission’s Compliance and Practices Division at (512) 804-4700.