Transcript Texas Health Care Network

Texas Health Care Network - Employer
Presentation
Texas Health Care
Network –
Employer Presentation
What’s New
• Texas House Bill 7 (HB-7)
• Health Care Networks
• Coventry Workers’ Comp Network
• Out of Network Care
• Employer and Employee Roles and Responsibilities
• Claim Roles and Responsibilities
• Case Management Roles and Responsibilities
• Employee and Employer Tool Box
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Texas Health Care
Network –
Employer Presentation
HB-7
• Abolishes TWCC.
• Creates the Division of Workers’ Compensation (DWC) administered as a division of
the Texas Department of Insurance (TDI).
• TDI approves and regulates the use of medical provider networks.
• Requires networks to select medical treatment guidelines which network physicians
must follow.
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Texas Health Care
Network –
Employer Presentation
Health Care Networks
• Allows insurance carriers to create or contract with a network.
• Allows voluntary participation in a certified network at the employer level.
• Limits choice of physician to doctors selected by the network.
• Employees receive care for workplace injuries through the network IF they live in the
network’s service area.
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Texas Health Care
Network –
Employer Presentation
Why participate in a Health Care Network?
• Employee selects treating doctor at time of injury.
• Employer and carrier have more control over direction of care and medical treatment.
• Referral to appropriate specialty care is channeled within network.
• Network providers and emergency care must be available and accessible 24 hours a day,
seven days a week.
• Focus on treatment and return-to-work outcomes.
• Improved quality of care.
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Texas Health Care
Network –
Employer Presentation
Coventry Workers’ Comp Network
• CNA has contracted with Coventry to utilize the Coventry Workers’ Comp Network.
• The Coventry Workers' Comp Network meets all state access and availability requirements.
Primary care will be available within 30 miles in non rural areas, and 60 miles in rural
areas. Specialty and hospital care will be available within 75 miles.
• The Coventry Workers’ Comp Network includes a continuous and comprehensive Quality
Improvement program that is in accordance with state specific requirements.
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Texas Health Care
Network –
Employer Presentation
Coventry Workers’ Comp Network – cont’d
• The Coventry Workers’ Comp Network includes a complaint process accessible to all
injured workers.
• The Coventry Workers’ Comp Network provides a toll free 800 number to assist
injured workers in finding a network physician.
• Network service area currently covers the greater Texas metropolitan areas, with
anticipated extended coverage to include 97% of the workforce population.
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Texas Health Care
Network –
Employer Presentation
Out of Network Care
• Carriers are responsible for out of network care involving:
• Emergency care.
• Care outside the service area.
• Care that has been referred and approved by the carrier.
• Care where the employee has not received appropriate notice of network requirements.
• The Approved Doctor’s List (ADL) remains in existence at least until September 1, 2007 for
non-network care.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibility of Employer
• Prior to implementation, the employer must provide each employee with a letter and handbook entitled Employee
Notification of Network Requirements.
• Each employee must sign an acknowledgement form that states the information was received.
• Employers should document to whom the notice was delivered, the method of delivery, the location of delivery and the
date of delivery.
• An employee who does not sign the acknowledgement form still must comply with the network requirements.
• The employee handbook includes information about the employee’s right to receive care from their HMO primary care
doctor if they receive group health benefits from an HMO. The HMO doctor must agree to abide by the network’s terms
and conditions.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibility of Employer – cont’d:
• Post notice of network requirements at each place of employment.
• Provide the employee acknowledgement letter and handbook to new employees no later than the third day after the date
of hire.
• Provide the employee acknowledgement letter and handbook to an injured employee at the time the employer receives
actual or constructive notice of an injury.
• If the employee refuses to use the network, any out of network expenses may be the liability of the employee.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibility of the Employee
• Read and acknowledge receipt of the Employee Notification of Network Requirements.
• If employees would like to use their HMO primary treating physician as their network treating doctor, they
must fill in that doctor’s name at the time of notification.
• If they have an emergency, they should be instructed to get immediate medical care.
• When an injury occurs, they should choose a treating doctor from the network list.
• For existing claims, they should select a treating doctor from the network list within 14 days or a treating
doctor will be selected for them.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibility of the Employee – cont’d
• If they wish to change a treating doctor, they must choose a doctor from the network
list. Change to a third doctor requires permission from CNA.
• Employees may have to pay for medical expenses if they do not use a network doctor.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibility of Claim Adjuster
• Direct care into the Coventry Workers’ Comp Network.
• Coordinate return-to-work with employer.
• Refer out of network referral request to Nurse Case Manager for review.
• Document selection of alternate treating doctor.
• Approve subsequent treating doctor requests.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibilities of Case Management
• Direct care into the Coventry Workers’ Comp Network.
• Coordinate return to work with employer.
• Review out of network referral requests.
• Provide in-network alternatives to requesting provider or injured worker.
• Contact HMO providers, when applicable, to inform them of network requirements.
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Texas Health Care
Network –
Employer Presentation
Role and Responsibilities of Case Management – cont’d.
• Review continuity of care impact on existing claims in determining whether to transfer
care into the HCN.
• Facilitate selection of a network treating doctor on existing claims.
• Document selection of alternate treating doctor.
• Approve subsequent treating doctor requests.
• Coordinate health care services and facilitate return to modified duty and full duty
work.
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Texas Health Care
Network –
Employer Presentation
Employer and Employee Tool Box
• Visit the CLAIM page within http://www.cna.com to access:
− Employee Communication Materials.
− Frequently Asked Questions.
− Agent and Employer Presentations.
• Provider Look up - http://www.geoaccess.com/cvty/Client.asp; Client ID: TXHCN.
• Single point of contact for provider search, provider list or provider nominations through Case Management Provider
Coordinator: Alyson Arguijo 866-401-9667.
• 800-873-0055 for network questions.
• Your CNA Client Service Director, Claim Consultant, or Case Manager.
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