June 21, 2018

TDI-DWC Finalizes Health Care Providers Pain Management (Opioid) Plan Based Audit

Austin, TX – On April 10, 2012 the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) solicited and received constructive input from workers’ compensation system participants on its initial plan to audit opioid utilization in the Texas workers’ compensation system. All comments were carefully considered and discussed. In response, the TDI-DWC has revised the proposed Health Care Providers Pain Management (Opioid) Plan-Based Audit. This revision has been approved by the Commissioner of Workers’ Compensation.

Scope of Audit: The approved Health Care Providers Pain Management (Opioid) Plan-Based Audit will focus on the opioid prescribing patterns of health care providers that are inconsistent with treatment recommendations outlined in the TDI-DWC adopted treatment guidelines – The Official Disability Guidelines – Treatment in Work Comp (ODG) published by the Work loss Data Institute. Specifically, the Opioid Plan-Based Audit will review the top fifteen health care providers (in terms of claim volume) who have prescribed opioids to employees injured in Calendar Year 2010 where:

  • the initial opioid prescription was less than 10 days from the date of injury;
  • the total day supply of opioids for the injured employee is greater than 30 days; and
  • the health care provider audit subject was the only health care provider prescribing opioids to the injured employee during the audit timeframe.

In response to comments, the TDI-DWC will include surgical claims in this initial audit. However, any claims that had a surgical procedure in the first 60 days from the date of injury will be excluded in order to focus attention on those claims where the medical necessity and appropriateness of opioid use is questionable.

The Medical Quality Review Panel will assess the medical necessity and appropriateness of prescribing opioids in cases selected for this Plan-Based Audit by using their professional expertise and knowledge, in addition to:

  • the ODG treatment guidelines;
  • the return-to-work guidelines adopted by the TDI-DWC (the Medical Disability Advisor, Workplace Guidelines for Disability Duration published by the Reed Group) for return-to-work outcomes;
  • nationally recognized, evidence-based medicine standards;  generally accepted standard of care; and
  • any other relevant information.

Other Plan-Based Audits: Some of the comments received for this initial audit of opioid utilization will be considered in the development of the 2013 Annual Audit Plan, which will be posted for system participant input later this year. As part of the 2013 Annual Audit Plan, the TDI-DWC tentatively plans to do a follow-up opioid utilization audit that focuses attention on legacy claims that are still receiving opioids during the transition to the closed pharmacy formulary.

All medical quality reviews initiated on or after January 1, 2011 will be performed in accordance with the approved procedure. The procedure and Plan-Based Audit are posted on the TDI website at http://www.tdi.texas.gov/wc/hcprovider/medadvisor.html.

Source: TDI-DWC

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