Workers' Compensation Terms in Texas
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Questions and Answers

Which of the following best describes an 'out-of-network' healthcare provider in the context of workers' compensation?

  • A provider who is under contract with a health maintenance organization but not a workers' compensation network.
  • A provider who specializes in occupational diseases but is not employed by the company.
  • A physician, healthcare provider, or hospital not contracted with a relevant network. (correct)
  • A provider who has completed all required training and certification.

    • What is the primary role of the Office of Injured Employee Counsel (OIEC)?

  • Providing legal representation to all injured employees.
  • Managing the Official Disability Guidelines database.
  • Overseeing performance assessments of insurance carriers.
  • Assisting injured workers with their workers' compensation disputes. (correct)

    • What constitutes an 'occupational disease' in the context of workers' compensation?

  • A sickness or disease arising while an employee is performing their job duties. (correct)
  • Any infectious disease from outside the workplace that causes the employee to miss work.
  • Any illness or disease an employee contracts, regardless of where it originated.
  • An illness that develops from a pre-existing condition independent of working conditions.

    • What does 'peer review' refer to in the context of healthcare within workers' compensation?

    <p>A chart review (not in person) of a claimant's health care medical records. (A)</p> Signup and view all the answers

    What is the primary role of an independent review organization in workers' compensation cases?

    <p>To determine the medical necessity and appropriateness of healthcare services provided to injured employees. (A)</p> Signup and view all the answers

    What are 'interrogatories' used for in regards to a DWC hearing?

    <p>To submit written questions to the other party prior to the hearing (B)</p> Signup and view all the answers

    What course of action can be taken if a party disagrees with a decision made during the DWC dispute resolution process?

    <p>Appeal the decision for judicial review. (D)</p> Signup and view all the answers

    What is the minimum impairment rating an employee must have to apply for supplemental income benefits (SIBs)?

    <p>15% (A)</p> Signup and view all the answers

    If an employee sustains a work-related injury causing wage loss, what type of benefits may they be eligible for after a seven day waiting-period?

    <p>Temporary income benefits (TIBs) (A)</p> Signup and view all the answers

    What is the role of a third-party administrator in the context of WC insurance?

    <p>To collect insurance premiums and adjust claims for an insurance carrier (A)</p> Signup and view all the answers

    What is the role of a treating doctor in the workers' compensation system?

    <p>To provide primary care to an injured employee and refer to specialists (B)</p> Signup and view all the answers

    An 'unjustified complaint' is characterized by which of the following?

    <p>A concern where there is no apparent violation of a standard. (A)</p> Signup and view all the answers

    What is the function of a utilization review agent?

    <p>To review medical services for necessity before, during, or after they are provided. (B)</p> Signup and view all the answers

    What is the role of an 'expert witness' in a workers' compensation case?

    <p>To offer their unique knowledge based on education or experience, that the average person does not possess. (A)</p> Signup and view all the answers

    What does the 'extent of injury' refer to?

    <p>The medical conditions that are part of an injured employee’s work related injury. (C)</p> Signup and view all the answers

    Which group is considered part of the 'first responder' category?

    <p>Paramedics working for a political subdivision in Texas (D)</p> Signup and view all the answers

    Which of the following best describes a 'political subdivision' in the context of workers' compensation?

    <p>A local government entity like a county or a school district that provides workers' compensation through a self-insurance pool. (C)</p> Signup and view all the answers

    What does a 'reconsideration' request involve?

    <p>A request to an insurance carrier to review its denial of medical services or income payments. (D)</p> Signup and view all the answers

    What is the significance of a 'pre-existing condition' in the context of WC claims?

    <p>A health condition that was present before an injury or before the WC insurance policy was put in place.</p> <p>This is a common way for an insurance company to deny medical treatment. (C)</p> Signup and view all the answers

    What is MMI (Maximum Medical Improvement)?

    <p>The point at which an injured employee's medical care has plateaued, and further medical improvement is very unlikely. (D)</p> Signup and view all the answers

    What is ODG?

    <p>The Official Disability Guidelines (A)</p> Signup and view all the answers

    What is a BRC (Benefit Review Conference)?

    <p>The first step in the TX WC dispute resolution process (B)</p> Signup and view all the answers

    What is a CCH (Contested Case Hearing)?

    <p>The second step in the TX WC dispute resolution process (C)</p> Signup and view all the answers

    What is the APD (Appeals Panel Decision)?

    <p>The third step in the TX WC dispute resolution process (B)</p> Signup and view all the answers

    What is "Judicial Review"?

    <p>The fourth step in the TX WC dispute resolution process (C)</p> Signup and view all the answers

    Flashcards

    Independent review organization

    A certified organization that reviews workers' compensation cases for medical necessity.

    Injured employee

    A person hurt while performing job-related activities for their employer.

    Insurance carrier

    An entity that provides medical and income benefits to injured employees.

    Interlocutory order request

    A request to pay or stop paying benefits until a dispute is resolved.

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    International Association of Industrial Accident Boards and Commissions

    An organization that standardizes data collection for workers’ compensation.

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    Interrogatories

    Written questions exchanged between parties during a DWC hearing discovery process.

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    Judicial review

    Appealing a DWC decision to a higher court for review.

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    Justified complaints

    Valid concerns about policy or rule violations in medical practice.

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    Over the counter drugs

    Medicines available for purchase without a prescription.

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    Occupational disease

    Sickness that arises from performing job duties.

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    Occupational hazard

    Conditions at work that increase injury or illness risk.

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    Peer review

    Evaluation of health care by similarly qualified professionals.

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    Permanent impairment

    Lasting damage from a work-related injury.

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    Plain Language Requirement

    Federal agencies must use clear language in communications.

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    Health Insurance Policy

    A written contract outlining claims insurers must pay.

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    Political Subdivision

    Local governments that offer workers' compensation via self-insurance.

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    Preauthorization

    Requesting insurance approval for treatment before it occurs.

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    Precertification Authorization

    Doctors submit treatment plans for insurer cost approval.

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    Pre-existing Condition

    A health issue present before receiving treatment.

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    Premium

    The cost of insurance protection for specific risks.

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    Quality Improvement

    Programs to enhance insurance carrier processes and services.

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    Reconsideration

    Requesting a review of a denial for services or payments.

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    Network Referrals

    Requests to see specialists within or outside a network.

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    Subscriber

    Employers providing workers’ compensation benefits to employees.

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    Subrogation

    Insurance carrier's right to pursue claims against third parties after paying a workers' comp claim.

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    Subsequent Injury Fund

    Fund to encourage hiring employees with pre-existing conditions and assist with new injuries.

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    Supplemental Income Benefits (SIBs)

    Benefits paid to injured employees after impairment income benefits end, requires application.

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    Temporary Income Benefits (TIBs)

    Benefits for injured employees losing wages for over seven days due to work-related injury.

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    Third Party Administrator

    Company handling insurance premiums, contributions, or claims for an insurance carrier.

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    Treating Doctor

    Physician providing primary care and specialist referrals for work injuries.

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    Unjustified Complaint

    Concern with no apparent violation of standards, rules, or laws.

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    Underwriter

    Person evaluating risks to set insurance rates and coverage.

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    Utilization Review

    Process monitoring quality and necessity of health care to reduce costs for insurers.

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    Experience

    The amount of workers’ compensation claims an employer has.

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    Experience modification

    The percentage change in insurance premiums based on claim losses.

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    Experience rating

    Adjusts workers' compensation premiums by comparing an employer’s losses to industry averages.

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    Expert witness

    A person with specialized knowledge in a subject beyond the average person's understanding.

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    Extent of injury

    The medical conditions related to a work-related injury of an employee.

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    Facility-based provider

    A healthcare provider associated with a medical facility.

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    Formulary

    A list of pre-approved prescription drugs for treatment.

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    First responder

    Emergency personnel such as police, firefighters, and paramedics.

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    Fringe benefits

    Extra benefits paid to employees beyond their salary.

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    Geographic service area

    The region where healthcare benefits are accessible for injured employees.

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    Study Notes

    State Specific Terms - Texas

    • Act: A set of Texas workers' compensation laws designed to protect both the employer and employee.
    • Act of God: An event caused by natural forces with no human involvement, such as floods, lightning, or earthquakes.
    • Adjuster: A representative of the insurance carrier who determines if the carrier is responsible for a claim and pays benefits if owed.
    • Administrative review: Examines a dispute's outcome, for example, the DWC Appeals Panel reviewing an administrative law judge's decision.
    • Adverse determination: A utilization review agent's finding that the health care services provided to an injured employee are not medically necessary, or are experimental or investigational.
    • Agent: A person who sells and services insurance policies; they must have a license from the Texas Department of Insurance (TDI).
    • Agent's license: A certificate of authority from the state allowing an agent to conduct business.
    • Agreement (in workers' compensation): A legal contract between parties involving an offer and acceptance, written on form 024, Benefit Dispute Agreement. An administrative law judge or benefit review officer must approve the agreement.
    • Annuity: A regular payment of money, either yearly or in installments, made either by the insurer to the injured employee or their beneficiary.
    • Appeal: The right to take a case to a higher level for review if a party is dissatisfied with a decision from dispute resolution.
    • Average weekly wage (AWW): The average amount an employer paid an employee each week in the 13 weeks before their injury or illness.
    • Balance billing: The practice of charging an injured employee the difference between the total cost of medical services and the amount covered by insurance.
    • Benefit review conference: An informal meeting held between parties and a DWC benefit review officer to discuss claim disputes.
    • Benefits (in workers' compensation): Payment or medical care provided by an employer's insurance to an injured employee.
    • Beneficiary: A person who receives benefits under an employer's workers' compensation policy following the death of the injured employee.
    • Case management: Coordinating medical services for an injured employee to enhance care and reduce costs.
    • Case manager: An experienced professional who coordinates the necessary health care services for an injured employee.
    • Catastrophic event: An event beyond one's control that interrupts the processing of claims for over two business days.
    • Certified network (workers' compensation): The TDI-certified healthcare delivery system of physicians and providers who make contracts to deliver medical and health care services to injured employees.
    • Certified self-insurer: A private employer who is approved to insure their own workers' compensation claims.
    • Certificate of authority: Gives an insurer the power to write insurance contracts in Texas and the powers granted to its agents.
    • Claim: A formal demand for benefits or a report of a workplace injury, filed by or on behalf of the injured employee.
    • Claimant: The person seeking payment of benefits.
    • Claimed injury: The work-related injury, disease, or illness for which an employee is claiming benefits from the insurance carrier.

    Continued

    • Classification: Grouping employees insured under a workers' compensation policy based on similar job characteristics and risk.
    • Compensable injury: An injury or illness that occurred while an employee was performing their job duties.
    • Complaint: A written statement alleging a violation of a workers' compensation law or rule.
    • Contested case hearing (CCH): A hearing held when disputes can't be resolved informally. All parties present evidence and arguments before a DWC administrative law judge.
    • Contested case hearing decision: A written decision from a DWC administrative law judge that resolves disputes on benefits, including findings of fact, conclusions of law, and whether benefits are owed.
    • Contributing injury: A previous work injury, medically proven to have lasting harm or impairment; impacts benefits due to the current injury.
    • Contribution: In certain situations, the insurance carrier can ask to reduce benefits if there is a prior work-related injury.
    • Course and scope: An injury that occurs while an employee is performing duties related to their employment and furthering the business interests of their employer.
    • Coverage verification: A method to check if an employer had workers' compensation insurance coverage on a specific date, usually done by the TDI website.
    • Date of service: The date healthcare services were provided by a healthcare provider or attorney.
    • Death benefits: Payments to families when an employee dies due to a work-related injury or illness.
    • Delegation: The process of appointing a person or group to perform specific tasks on behalf of another.
    • Designated doctor: A doctor chosen by the DWC to resolve disputes about medical conditions or work-related injuries.
    • Disability: An employee may have a disability if an injury prevents them from earning the wages they made in the 13 weeks before the injury; this is income loss from job, not a physical or mental condition.
    • Direct result: A requirement for supplemental income benefits, showing that the work-related injury was substantial, caused lasting effects (impairment), and prevents the employee from doing their job.
    • Dispute: A disagreement between parties in a workers' compensation claim, commonly about benefits or payment amounts.
    • Documentary evidence: Supporting documentation used in a workers' compensation case, including reports, medical records, or statements.
    • DWC: The Texas Department of Insurance, Division of Workers' Compensation.

    Continued

    • Electronic Data Interchange (EDI): Electronically transferring claim, medical, and insurance coverage data to DWC by the insurance carriers.
    • Emergency care: Includes medical or behavioral health services for severe pain, risks to health, disabling functions or significant issues to a pregnant woman or unborn child.
    • Exceptions to liability: Reasons why the insurance carrier might not be liable for a worker’s compensation claim (e.g., injuries happening off-duty, un-reported on time, or due to intoxication).
    • Exchange: Information that all parties in a claim must share before a conference or hearing concerning benefits.
    • Existence, duration, or extent of disability: Common disputes about whether a disability exists, its duration, or if it’s connected to a compensable injury.
    • Expedited: A quicker way to complete a process or action.
    • Experience: The total amount of claims (losses) resulting from workers' compensation an employer has incurred.
    • Experience modification: An adjustment to insurance premiums based on an employer's experience with workers' compensation claims.
    • Experience rating: Assessing insurance premiums based on an employer's workers' compensation loss experience compared to similar employers' loss experiences.
    • Expert witness: A person with special knowledge in a subject matter, by training or expertise.
    • Extent of injury: The range of medical issues related to the injuries sustained.
    • Facility-based provider: A healthcare provider working in a facility or facility-based setting, such as an emergency room, orthopedic surgeon or physical therapist.
    • Formulary: Authorized prescription drug list by insurance.
    • First responder: Emergency service workers (e.g. police, paramedics and other emergency medical personnel) in a political subdivision of Texas.
    • Fringe benefits: Compensation, over and above an employee's salary, such as health insurance, car allowance, or dry cleaning.
    • Geographic service area: Area where workers' compensation health care services are accessible. For injured employees, if the employer is within a network, services must be provided in that network's area.

    Continued

    • Good cause: A legitimate reason for taking or not taking an action.
    • Health care facility: Place that provides healthcare (e.g., hospital, emergency clinic, outpatient clinic).
    • Health care practitioner: Someone licensed or otherwise authorized to provide health care, even if not a medical doctor or M.D.
    • Health care provider: Health care facilities or practitioners.
    • Health Insurance Portability and Accountability Act of 1996 (HIPPA): A law concerning the national standards and national identifiers for healthcare transactions, and security/privacy of healthcare data
    • Impairment income benefits (IIBs): Income payments if an injury affects the body as a whole.
    • Impairment rating: A rating that shows what percent a work-related injury affects the entire body, as assigned by a health care provider
    • Independent review organization (in workers' compensation): An organization that reviews cases and establishes if the medical and health care provided to the injured employee is medically necessary and appropriate.
    • Injured employee: A worker hurt while performing work duties.
    • Insurance carrier: Provides medical and income benefits to injured workers. An insurance company, self-insurer, self-insurance group or governmental entity.
    • Interlocutory order request: Asking for a decision on medical or benefit payments to be held until a dispute is decided during a contested case hearing.
    • International Association of Industrial Accident Boards and Commissions (IAIABC): An organization related to workers' compensation that provides standards and data collection tools for states, analyzing policies, and suggesting model laws.
    • Interrogatories: Formal questions sent during case discovery.
    • Judicial review: The process of an injured employee appealing a DWC dispute to a court.

    Continued

    • Justified complaints: Valid concerns regarding violations of policies or rules in a medical or business setting.
    • Large group employer: An employer with 51 or more eligible employees in a previous year.
    • Letter of clarification: A letter sent by concerned parties to DWC for further information regarding a designated doctor’s report concerning a worker's injury.
    • Lifetime income benefits (LIBs): Long-term benefits for severe injuries.
    • Malinger: To falsely claim an injury to get more benefits than warranted.
    • Maximum medical improvement: When an injured worker’s healing process is finished.
    • Medicaid: A state and federally funded health care program for eligible residents.
    • Medical fee dispute resolution: A DWC process for resolving disagreements on healthcare costs for treating work-related injuries by an employee.
    • Medical necessity: If medical services are needed to diagnose or treat an injury, illness, condition, or disease in accordance to medical standards/practice.
    • Medically necessary: A service that will affect the patient's healthcare condition negatively if not performed, determined by a medical or healthcare professional.

    Continued

    • Misrepresentation: Providing inaccurate information regarding terms or benefits of a policy or regarding a worker's injury.
    • Multiple employment: An employee having multiple jobs at the time of injury.
    • National Association of Insurance Commissioners (NAIC): An organization regulating insurance; providing analyses & developing model laws for state legislators.
    • National Council on Compensation Insurance (NCCI): An organization, operating as a rating organization, that provides statistics on workers' compensation, develops policy forms and rates, and makes filings for its members to the states.
    • National Provider Identifier (NPI): A unique identifier for healthcare providers which is used on all forms; required by Medicaid and other services.
    • Network (in workers' compensation): Physicians who contract with an insurance carrier to treat injured workers of an employer in a specific area.
    • Non-network (in workers' compensation): Medical services given outside of the contracted healthcare provider network of the insurer.
    • Non-subscriber: An employer who does not provide workers' compensation coverage for their employees.
    • Notice of denial: Notification that insurance carriers send when benefits are not going to be provided.

    Continued

    • Notice of continuing investigation: Notification for insurance carriers when further information is needed regarding a claim to determine compensability; sent to the injured employee & DWC.
    • Notice of network requirements: Contains information regarding the requirements of an employer who's involved in a network, for injured employees.
    • Occupational disease: Illness resulting from prolonged exposure to work conditions.
    • Occupational hazard: Condition that increases the risk of injury or illness at work.
    • Office of Injured Employee Counsel (OIEC): Agency apart from DWC, which assists workers' with disputes concerning workers' compensation.
    • OIEC ombudsman: Provides support to injured employees who have disputes about workers' compensation, without having an attorney.
    • Official Disability Guidelines: Health care providers use this as a database to decide how to best treat an injured worker and when they can safely return to work.
    • Over the counter drugs: Medications available without a prescription.
    • Out-of-network: Health services provided by a healthcare provider who does not have a contract with the insurance carrier.
    • Parent company: The senior company within a group of insurers or other businesses.

    Continued

    • Peer review: Review of another healthcare professional's performance on a medical treatment, performed by someone with similar or equal training.
    • Performance based oversight assessment: The DWC uses this to measure an insurance company's and healthcare provider performance every two years. Poor, average, or high tiers are assigned.
    • Permanent impairment: Damage to an injured employee from a work-related injury that causes a lasting affect.
    • Pertinent information: Important details that are needed to resolve disputes, such as witness accounts, police reports, and medical records.
    • Plain language: Language understandable on first reading and understanding.
    • Policy: The contract between insurer and policyholder outlining the claims payable by the insurer.
    • Political subdivision: Local government bodies like counties, cities, districts, and housing authorities who offer work compensation coverage.
    • Preauthorization: Insurance approval of medical treatment before it is given.
    • Precertification authorization: The process for an insurer to determine the appropriateness and amount of medical procedures and treatment and rates, and to inform the insured employee as well as their caregiving personnel(e.g,doctor).
    • Pre-existing condition: Health concern present prior to a work-related injury.
    • Premium: Cost of insurance protection over a set period of time.

    Continued

    • Quality improvement: Measures and corrects deficiencies/errors impacting an insurance carrier's procedures and processes or health care network
    • Reconsideration: Request from an injured employee or healthcare provider to review the denial of medical services or income payments.
    • Referrals (in-network): A request to another healthcare provider for a specialist who is part of the insurance carrier’s network.
    • Referrals (out-of-network): A request to a specialist when the requested service is not in the insurance carrier’s network.
    • Remand: When a DWC Appeals Panel sends a case back to a contested case hearing for additional action.
    • Representative: A person, such as an attorney, who helps an injured employee, beneficiary or insurance carrier concerning benefits payments.
    • Required medical exam: A medical examination required by the DWC for an injured employee when there is concern regarding appropriate or needed care or diagnosis when there is a disagreement on a medical diagnosis.
    • Retrospective review: Review to determine if medical services given were appropriate and necessary after the services are finished.
    • Rules: DWC's stated laws and policies, generally published in the Texas Administrative Code.
    • Seasonal employee: Worker who has employment to fulfill temporary needs of the employer.
    • Secure File Transfer Protocol (SFTP): A secure protocol for sending documents electronically to DWC.

    Continued

    • Self-insured governmental entity: State, county, and local entities that self-insure workers' compensation coverage for employees.
    • Self-funded/self-insured benefit plans: Alternative plan to worker's compensation.
    • Showing good cause: Providing a valid reason for taking or not taking an action.
    • Small group employer: A person or entity employing 2-50 eligible employees in a calendar year.
    • Solvency: Having sufficient funds to conduct the insurance business and cover liabilities.
    • Statewide average weekly wage: The average weekly wages of Texas employees for a specified time period; calculated by the Texas Workforce Commission.
    • Statement: A written, spoken, or recorded fact.
    • Statutory: Required by a law or statute, such as Texas Labor Code.
    • Statutory maximum medical improvement: The date when an injured employee is deemed medically improved according to the time limits of the laws.
    • Subscriber: The employer who provides workers' compensation benefits for their employees.
    • Subrogation: When an insurance carrier, after paying a claim, takes over the right to pursue payments for benefits from another party.

    Continued

    • Subsequent Injury Fund: Fund administered by DWC to support employees with pre-existing conditions and new injuries.
    • Supplemental income benefits (SIBs): Additional income payments after the impairment income benefits stop, if a specific impairment rating is met.
    • Temporary income benefits (TIBs): Temporary financial payment assistance for loss of wages caused by a work-related injury or illness lasting longer than 7 days.
    • Third-party administrator: Company that processes insurance premiums or claims for an insurance carrier.
    • Treating doctor: Healthcare provider who provides primary care for an injured employee.
    • Unjustified complaint: Concern about a violation of policies or standards that are not valid.
    • Underwriter: Evaluates risks and sets rates for an insurance carrier.
    • Underwriting: Process of evaluating and classifying insurance risks.
    • Utilization review: Process of monitoring quality and appropriateness of healthcare for workers' compensation.
    • Utilization review agent (URA): An individual or organization who reviews healthcare services appropriateness and necessity.
    • Utilization management: Processes used to determine whether insurance-covered healthcare services are necessary.
    • Wage: Salary and other payments received as compensation for services.

    Continued

    • Wage statement: Employee's work-related earnings for the past 13 weeks before being injured, used in determining benefit amounts.
    • Workers' compensation: Insurance program for providing income and medical benefits, after a work-related illness or injury; not always required by employers.

    Addendum #2

    • Link to TX's WC Administrator: [https://www.tdi.texas.gov/wc/index.html]

    Addendum #3

    • Link to TX's annual reports: [https://www.tdi.texas.gov/reports/documents/2022-tdi-annual-report.pdf], [https://www.tdi.texas.gov/reports/documents/biennial-report.pdf]
    • BONUS 1: [https://www.tdi.texas.gov/reports/wcreg/index.html#wcreports (all reports)]
    • BONUS 2: [https://wwwapps.tdi.state.tx.us/inter/perlroot/sasweb9/cgi-bin/broker.exe?service=wcExt&program=progext.hsdata3.sas] (to look up claims by geographic area)

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