Transcript Document
Bunch’s Texas Workers’ Compensation Health Care Network (HCN) Employer Presentation Responsive. Caring. Committed. Created 3-07 Bunch’s Texas HCN - Background June 1, 2005 - Texas House Bill 7 signed into law allowing the implementation of Health Care Networks (HCNs) on or after January 1, 2006. December 2005 - Final regulations for the HCNs approved by the Texas Department of Insurance (TDI). January 2006 - TDI begins reviewing submitted network filings. Responsive. Caring. Committed. 2 Bunch’s Texas HCN – Health Care Network What is a Health Care Network (HCN)? - A HCN is a network of providers that has been certified by the Texas Department of Insurance (TDI) to provide workers’ compensation health care to injured workers. - TDI certification ensures all specific requirements, including access and health care delivery standards, have been met. - Only those Geographic Service Areas (GSAs) that meet all health care access requirements will be approved. - Once certified, the network will continue to be monitored by TDI for quality and outcome measurements. Responsive. Caring. Committed. 3 Key Points of HCN Regulations An injured worker who lives* within an approved GSA must seek treatment within the HCN. The employer may direct the initial non-emergency care to the HCN provider of choice. Health care for the work-related injury or illness is to be delivered within the HCN for the life of the claim. The employer has the ability to transfer care for existing WC injuries into the HCN. * Denotes the employee’s principal residence that is not a PO Box, a temporary residence required by employment or and address used for receiving help with daily activities Responsive. Caring. Committed. 4 Key Points of HCN Regulations (continued) Providers who leave the network may be allowed to continue to treat in order to maintain continuity of care. The network specifies who can be considered a treating provider for the purposes of directing an injured workers treatment plan. The rules have given an allowance for an injured worker to use their HMO treating provider (PTP) for the work-related injury if they designate their PTP prior to the injury. Responsive. Caring. Committed. 5 Major Requirements for a TX HCN TDI network access criteria Specific provider contract requirements Provider credentialing standards Complaint and grievance process Third party contracting requirements Utilization review and case management requirements Employee notification process Treatment and return-to-work guidelines Quality improvement plan Responsive. Caring. Committed. 6 Network Access Requirements for GSAs Adequate treating doctors, hospitals and specialists available 24/7 In-patient and emergency care services within contracted general acute, specialty and psychiatric hospitals Treating doctors or general acute hospitals accessible within 30 miles in non-rural, 60 miles in rural areas Specialists accessible within 75 miles Adequate number of doctors able to provide MMI / IR A contracted general acute hospital within each non-rural county Responsive. Caring. Committed. 7 Bunch’s Texas HCN – Case Management / UR HCN Case Management and Utilization Review Requirements - Approved TX UR Agent - Medical Director must be licensed in Texas and be board certified in occupational medicine - Claim handlers may not perform case management functions Case managers: - Certified by a national accrediting agency - Provide triage to assess the injury - Work with the treating provider, claim handler and employer to implement and coordinate a treatment plan - Evaluate options and services needed to provide appropriate medical care and facilitate timely return-to-work - Ensure continuity of care for injured workers Responsive. Caring. Committed. 8 Bunch’s Texas HCN – Enrollment Employee Notification Distribute the Employee Enrollment Package to all active Texas employees at the following times: - Prior to implementation of the HCN Within 3 days of a new employee being hired in Texas When an employee is injured Whenever a material change in the HCN occurs Your claim handler will identify employees with existing injuries and evaluate them for potential transfer into the HCN. Responsive. Caring. Committed. 9 Bunch’s Texas HCN – Enrollment Guide The Employee Enrollment Guide consists of the following: - Employee Notification Letter as approved by TDI for HCN filing - Attachment A – Selecting a Provider through ProviderNet - Attachment B – Aetna TX HCN – Certified Counties - Attachment C – Treatment Guidelines - Attachment D – Description of Complaint System - Attachment E – Summary of Independent Review Process - Attachment F – Employee Acknowledgement Form Responsive. Caring. Committed. 10 Bunch’s Texas HCN - Distribution Any of the following methods may be used to distribute the notice and acknowledgment form to your employees: - Distribute the notice to employees at a scheduled staff or safety meeting and collect signed acknowledgment forms. Have a witness available if an employee refuses to sign the form. - Send a hard copy of the notice and acknowledgment form to all employees with a self-addressed return envelope for the acknowledgement form. - E-mail the notice to all employees and attach the acknowledgment form. Ask employees to complete and return the acknowledgment form. - Distribute the notice to employees electronically and obtain an electronic signature for your records. Distribution of the information to employees must be documented (who, what, where and when). Responsive. Caring. Committed. 11 Bunch’s Texas HCN – Next Steps Work with your account manager to ensure you are following the correct employee notification process Set a date for implementation of the HCN. Allow sufficient time for enrollment and collection of employee acknowledgment forms. Start directing care for any new injuries that occur on or after the implementation date Distribute the Employee Notification Package again to all employees who report a new work-related injury or illness after the implementation date Responsive. Caring. Committed. 12