Texas Clarifies Rules on Designated Doctors, Peer Reviewers

The qualifications and functions of designated doctors and peer reviewers in the Texas workers’ compensation system are clarified in rules adopted by Commissioner of Workers’ Compensation Albert Betts in late July. These rules were necessary to implement changes in the Texas Labor Code under House Bill (HB) 7 (79th Legislature).

Designated doctors are assigned by the Texas Department of Insurance, Division of Workers’ Compensation (DWC) to recommend a resolution of a dispute over the medical condition of an injured employee. Peer reviewers are health care providers who, at the request of insurance carriers, perform administrative reviews of the health care provided in a workers’ compensation claim.

“The intent of the designated doctor and peer reviewer rules is to improve the quality of health care provided to injured employees and to monitor peer review activities in the workers’ compensation system,” Commissioner Betts said.

The peer reviewer rules (28 Texas Administrative Code §180.22 and new §180.28) will be effective August 16, 2006. The designated doctor rules (28 TAC §180.21) will be effective in January 2007. The rules are posted on the TDI Web site at: http://www.tdi.state.tx.us/wc/rules/adopted/adopted.html.

Commissioner Betts also recently adopted rules allowing insurance carriers, health care providers and DWC to exchange medical billing data electronically (28 TAC §133.500 and §133.501). And the Commissioner adopted rules allowing insurance carriers to request an examination of an injured employee by his or her treating doctor specifically to define the work-related injury (28 TAC §126.14). These rule adoptions comply with Texas Labor Code changes under HB 7; the electronic medical billing rules are effective Aug. 10, 2006 while the treating doctor examination rule was effective July 9, 2006.

Source: Texas DWC