TDI-DWC Issues 2012 Audit Plan - Texas Journal of Chiropractic

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TDI-DWC Issues 2012 Audit Plan

Published 01/18/2012 - 2:09 p.m. CDT

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On December 12, 2011 the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) solicited and received input from workers’ compensation system participants. All comments were carefully considered and discussed. The Commissioner of Workers’ Compensation Rod Bordelon approved the revised CY (Calendar Year) 2012 Annual Audit Plan (Annual Plan) on January 11, 2012.

Some of the reasons for not making additional changes to the Annual Plan are outlined below.

Individual Plan-Based Audits: Some of the comments received requested that the TDI-DWC include the specific review criteria for each individual plan-based audit. The Annual Plan sets the priorities for what types of audits the Medical Quality Review Panel (MQRP) will focus on for the next year.

At a future date, the TDI-DWC will obtain stakeholder input on the development of each individual plan-based audit proposal listed in the Annual Plan. Each individual plan-based audit proposal posted for comment will include:

• inclusion and exclusion criteria;

• service time frame to be audited;

• sample size;

• subject and case file selection criteria; and

• types of MQRP members to be assigned to perform the medical quality review.

Complaint Process: A commenter noted that the TDI-DWC should have the ability to investigate internal referrals of violations. Internal referrals are complaints and are processed according to the approved MQRP procedure. Furthermore, the approved MQRP procedure permits MQRP Members or the Medical Advisor to expand the scope of an investigation.

Audit Purpose: A comment was received regarding the emphasis on injured employee health and safety as outlined in the proposed Annual Plan under Section II Purpose. While the TDI-DWC is concerned about all violations of statutes or rules, the primary focus of these audits is those violations that affect the health and safety of the injured employee. However, as stated above, individual plan-based audits will be developed later, and they may have some aspect not primarily related to injured employee safety.

All medical quality reviews initiated on or after January 1, 2011 will be performed in accordance with the approved MQRP procedure. The Procedure and Annual Plan, including any changes, are posted on the TDI website atwww.tdi.texas.gov/wc/hcprovider/medadvisor.html.
If you have any questions contact Carol Ann Sherman at 512-804-4821 or Carol.Sherman@tdi.state.tx.us.

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