QRL’s - June 2002 - present
20020611
13
DESIGNATED DOCTOR / TWCC-32 /
When a field office is requesting a designated doctor appointment, would it be appropriate to fax the entire TWCC-32 or should only the first page be sent?
20020618
Only the first page should be sent as the matrix is only a tool for the commission to use in choosing the doctor.
20020611
14
BILLING SERVICES / TWCC-69 / RULE 130.1 (C)(3) / CLINICAL MMI /
A provider has been instructed by an insurance carrier to file TWCC-69 on every claim based on box #17 Clinical MMI. Is it the commission's interpretation that a 69 should be completed on all claims?
20020618
No. Rule 130.2(a)(2) provides that except for a commission request for an impairment rating at 98 weeks there is no requirement for a treating doctor to schedule an examination if the employee has been released from treatment and is not receiving TIBs. Therefore, a TWCC-69 is not required for every claim.
20020627
15
PEER REVIEW / DESIGNATED DOCTOR / MEDICAL RECORDS / MEDICAL OPINION /
Can the carrier send a peer review that they had done prior to the designated doctor appointment to the designated doctor? Is the peer review considered "medical records" when it is really just a medical opinion and no physical exam has been done on the clmt?
20020709
A peer review completed by a healthcare provider which is included in the employee=s medical records maintained by the insurance carrier relating to an issue to be evaluated by the designated doctor, may be forwarded to the designated doctor in accordance with 408.0041(c).
Only the designated doctor may initiate communication with peer reviewers identified by the insurance carrier per 408-0041(d).
20020711
16
401K RETIREMENT PLAN / FRINGE BENEFITS / VESTED INTEREST /
Would the match that an employer makes in a 401 K plan be considered a fringe benefit, i.e. the employee puts in $100 and the employer matches the $100? Would vested or not vested play a part in this?
20020723
Employer matches to 401k plans are considered a pecuniary fringe benefit that vests on the effective date of payment to the 401k plan.
20020808
17
' 410.006 / CLAIMANT REPRESENTATIVE/ASSISTANT / BRC /
' 410.006 states that a claimant may be assisted by an individual of the claimant's choice who does not work for an attorney or receive a fee. Does this section of the law prohibit an individual, who works part time for an attorney, from assisting an unrepresented claimant at a BRC, even though that attorney has no connection to the claimant?
20020820
Yes, unless that person is related to the claimant. The statute makes an exception for a relative as long as no fee is paid.
20020128
04
DECISION AND ORDER / SUBSEQUENT INJURY FUND / OVERPAYMENT / LOSS RATIO / EMPLOYER LOSS RUN / PREMIUM / LOSS EXPERIENCE
If TWCC issues an order stating an injured worker was not entitled to benefits, after benefits have been paid by the carrier, there is an overpayment. It is my understanding that the carrier has the option of pursuing recovery from either the injured worker or the Subsequent Injury Fund.
If the carrier chooses not to pursue recovery of the overpayment from any available source, the overpayment shows up on the employer's loss runs. These paid losses become part of the loss ratio, and result in higher premiums for workers' compensation coverage.
Many employers are faced with rising claim costs and, in turn higher insurance premiums. A client of ours asked if there was anywhere to turn to get these "overpayments" taken off the loss experience so they would not have an adverse effect on his future loss ratios and premiums. He has spoken with carriers, legislators, and the Texas Department of Insurance, and no one seems to have any definitive answers.
The Commission has no jurisdiction over an employer’s loss ratio or premium dispute. The employer would need to put the dispute in writing and submit it to the Texas Department of Insurance, Workers’ Compensation Oversight Division for resolution.
20020215
05
DESIGNATED DOCTOR / ADDITIONAL TESTING / WHOLE BODY IMPAIRMENT / CARRIER DISPUTE / BODY PART / PURSUE / FINAL DETERMINATION /
An injured employee was sent to a designated doctor over dispute of MMI/IR. The doctor sent the injured employee out for EMG studies due to unexplained right-side muscle weakness. The test resulted in diagnosis of carpal tunnel syndrome. After receiving the report, the carrier disputes the CTS and the claimant agreed that the CTS is not related to the compensable injury.
Assuming that the final adjudication will result in a decision of "non-compensable for the carpal tunnel", will the injured employee be responsible for the cost of the testing ($1,260.38)? The injured employee believes that the carrier is liable for payment since the testing was done at the direction of the designated doctor and not requested by the injured employee.
20020219
The employee is not responsible for the cost of the EMG testing ordered by the designated doctor. The designated doctor’s evaluation of how the injury affects the whole body is required by law (Sections 408.122 and 408.125) when the determination of maximum medical improvement and assignment of impairment rating (MMI/IR) is in question.
The 1996 Medical Fee Guideline, Evaluation and Management ground rules, XXIII, E, 6, allows reimbursement for any testing determined to be medically necessary by the designated doctor in order to determine MMI and assign IR.
If EMG studies were medically necessary to diagnose the unexplained right side muscle weakness in order to determine the cause of and possible connection to the compensable injury and/or effect on the whole body permanent impairment, then the carrier should reimburse the designated doctor and any referral providers carrying out testing the designated doctor deemed medically necessary to evaluate MMI/IR.
20020326
06
SEASONAL EMPLOYEE / SEASONAL ADJUSTMENT OF TIBS / OVERPAYMENT / RECOUPMENT / DELAY BY COMMISSION /
TWCC staff delayed the approval of reduction of TIBs for seasonal adjustment and the carrier overpaid TIBs as a result. Can the carrier recoup the overpayment from TIBs for the seasonal adjustment?
20020416
Yes, the carrier is entitled to reduce TIBs for the eleven week period approved by the commission on 11-16-01for seasonal adjustment.
20020321
07
TREATING DOCTOR / REQUIRED MEDICAL EXAMINATION / CHANGE OF DOCTOR /
Can the RME doctor become the injured employees treating doctor?
20020423
Yes, Rule 126.9 allows an employee to request an alternate treating doctor who is on the ADL (except for a designated doctor who served on the employee’s claim). Rule 126.5(b)(1) gives the Commission the authority to approve the carrier's request to choose another doctor. If the carrier RME doctor becomes the treating doctor, the carrier would have to choose another doctor for any subsequent RME's.
20020409
08
DESIGNATED DOCTOR / CONTACT / EXAM / ATTENDANCE / APPOINTMENT /
Can a carrier contact the designated doctor's office after the scheduled exam date and time to confirm whether or not the employee attended the appointment?
20020423
The carrier can contact the office staff of the designated doctor to confirm whether the injured worker attended the examination. No further information can be discussed.
20020417
09
TWCC - 32 / SIGNATURE / HANDLING ADJUSTER / ADJUSTER FOR BOARD REP /
TWCC-32's are being received that are signed by an adjuster/attorney of the board rep and not the handling adjuster. Should these be denied since the handling adjuster is not signing the form?
20020423
As long as the form is signed by an adjuster/attorney that is a representative of the insurance company, it does not have to be the handling adjuster. The party signing the TWCC-32 is deemed to be guarenteeing the validity of the information on the matrix and if it is not valid, that person will be held responsible.
20020419
10
3RD EDITION / 4TH EDITION / STAT MMI / OCTOBER 15, 2001 / DESIGNATED DOCTOR / FIRST CERTIFICATION /
An injured employee reached statutory MMI on May 15, 2001. In January of 2002 the first certification was done using the 3rd edition. A designated doctor was selected and instructed to use the 4th edition to perform the impairment evaluation. Since stat mmi was reached on May 15, 2001, which edition should be used?
20020423
The statutory MMI date would have no bearing on the edition to be used. According to Rule 130.1(c)(2)(B) since the first evaluation was held after October 15, 2001, all certifications should have been done using the 4th Edition.
04/25/02
11
RME APPOINTMENT / DESIGNATED DOCTOR / WAIT TIME / NO SHOW /
What is a reasonable time that an injured employee should wait at the RME doctor's office or a designated doctor's office for a scheduled appointment? Along the same lines, what is a reasonable time the doctor should wait before the claimant is considered a "no show" for a scheduled appointment?
04/30/02
If the physician has not begun the examination of the injured employee within 1 hour of the scheduled examination and the employee had shown up on time and checked in with the receptionist, then the Commission believes good cause would exist for the employee to leave the doctor’s office without submitting to the examination and the carrier could not suspend compensation.
Each individual doctor’s office will have its own time line for no shows. The injured employee should contact the doctor’s office to reschedule the appointment as soon as possible once the employee knows he/she is not able to attend the appointment timely.
20020426
12
EXTENSION OF MMI / SPINAL SURGERY /
If an injured employee receives an extension of MMI because of a pending spinal surgery, and then decides to not have the surgery. Is the extension of MMI null and void?
20020518
If the injured employee decides not to have the surgery, the carrier may request a BRC and the Commission will determine if the order for extension should be rescinded on a case by case basis.
20021001
0303B
EXTENT OF INJURY / BRC / DESIGNATED DOCTOR / MULTIPLE CERTIFICATIONS /
When a claimant requests a BRC on extent of injury and dispute of designated doctor findings because if did not include the disputed body part, should new medical regarding the disputed body part be sent for the designated doctor to review?
20021001
Yes, Rule 130.6(d)5 requires the designated doctor to give multiple certification of MMI and impairment ratings that take into consideration the various interpretations of the extent of injury so that when the commission resolves the dispute, there is already an applicable certification of MMI and rating from which benefits can be paid from.
20021017
03-04
TWCC-69 / DESIGNATED DOCTOR / RULE 130.1 / RULE 130.3 / FILING REQUIREMENTS /
Treating doctors are stating they should receive a copy of the designated doctors findings, especially since the designated doctors report is at times the first certification of MMI/IR.
Rule 130.6(h) refers you to Rule 130.1. But when you review Rule 130.3 it does indicate that a doctor, other than the treating doctor who is authorized to certify that an employee has reached MMI, must do so in accordance with Rule 130.1 in addition to complying with the filing requirements, the certifying doctor shall file a copy of the report of medical evaluation & narrative with the treating doctor with in the same time frames for filing with other persons that 130.1 requires.
The new informational sheet re: DD disputes specifically states there is no requirement for them to provide a copy of the report to treating doctor.
Does the designated doctor not fall under 130.3 as a doctor other than the treating Dr.?
20021022
Yes. If a designated doctor certifies an employee’s MMI, Rule 130.3(a) requires any doctor other than a treating doctor who certifies MMI and/or impairment rating to file a copy of the Report of Medical Evaluation and narrative with the treating doctor within the same time frames for filing with other persons as required by rule 130.1. Rule 130.3 was amended effective January 2, 2002.
20021022
03-05
CHARTER SCHOOLS / COVERAGE /
Are (Chartered) schools required to carry W/C coverage?
20021022
"An independent school district may choose to operate under a charter in accordance with Texas Education Code, Chapter 12. Generally, a charter school (whether operated by a home-rule school district, by a campus or campus-program charter, or by a open-enrollment charter) is subject to federal and state laws and rules governing school districts. (Texas Education Code §§12.012, 12.055 and 12.103). As such, charter schools, as part of a school district ("political subdivision"), fall under the provisions of Texas Labor Code, Chapter 504, which requires political subdivisions to provide workers' compensation benefits to its employees."