December 11, 2017

TX Division of Workers’ Compensation Announces 2014 Enforcement Actions

Austin, TX – Commissioner of Workers’ Compensation Ryan Brannan recently announced final disciplinary actions taken by the Division of Workers’ Compensation (DWC) in 2014.

The final actions include administrative penalties ordered against insurance carriers, health care providers and employers in the workers’ compensation system. Since January 1, 2014, the Commissioner of Workers’ Compensation has ordered administrative penalties totaling $2,238,845 against system participants. The penalties include $2,086,395 in fines ordered against insurance carriers, $106,450 in fines ordered against health care providers, $45,000 in fines ordered against other entities and $1,000 in fines ordered against employers.

Violations of the Texas Labor Code and related rules by insurance carriers cited in recent orders include failing to timely pay income benefits to an injured employee, failing to timely pay a medical bill, and retrospectively reviewing the medical necessity of a preauthorized medical service or treatment. Violations cited in orders naming health care providers include administering unreasonable or medically unnecessary treatment or services and failing to adequately assess and monitor injured employees when prescribing opioids. Violations cited in orders naming other entities include adjusters performing utilization reviews and issuing medical necessity denials without allowing the health care provider a reasonable opportunity to discuss the clinical basis for a denial of preauthorization with the appropriate doctor or health care provider performing the review prior to the issuance of a preauthorization or concurrent review denial.

Summaries of orders from December 2014:

Ace American Insurance Company of Philadelphia, PA
Order Number: DWC-3743
Date of Order: 12/19/2014
Action Taken: Fined $1,000
Violation: Failed to provide list of all injured worker injuries determined to be compensable by TDI-DWC or as accepted as compensable by insurance carrier

Arch Insurance Company of Jersey City, NJ
Order Number: DWC-3696
Date of Order: 12/2/2014
Action Taken: Fined $700
Violation: Failed to timely comply with an order for advance payment of income benefits to injured employee

Chubb Indemnity Insurance Company of Warren, NJ
Order Number: DWC-3714
Date of Order: 12/11/2014
Action Taken: Fined $9,000
Violation: Failed to timely pay benefits based on the opinion of designated doctor during pendency of a dispute

City of Houston of Houston
Order Number: DWC-3752
Date of Order: 12/23/2014
Action Taken: Fined $8,000
Violation: Failed to comply with benefit dispute agreement

Dallas Medical Center of Dallas
Order Number: DWC-3695
Date of Order: 12/2/2014
Action Taken: Fined $15,000
Violation: Failed to respond to a request for a refund from insurance carrier

Eaves, Jason L., D.C. of San Antonio
Order Number: DWC-3729
Date of Order: 12/18/2014
Action Taken: Fined $1,000
Violation: Failed to timely file and/or accurately complete TDI-DWC forms, reports or records

El Paso Orthopedic Surgery Center of El Paso
Order Number: DWC-3730
Date of Order: 12/18/2014
Action Taken: Fined $2,000
Violation: Improperly billed an injured employee for wrokers’ compensation medical services provided

Everest National Insurance Company of Liberty Corner, NJ
Order Number: DWC-3742
Date of Order: 12/19/2014
Action Taken: Fined $25,000
Violation: Failed to timely act on a properly completed medical bill; Failed to timely submit accurate medical EDI records to TDI-DWC

Federal Insurance Company of Warren, NJ
Order Number: DWC-3713
Date of Order: 12/11/2014
Action Taken: Fined $4,000
Violation: Failed to timely pay income benefits to injured employee

Genesis Insurance Company of Stamford, CT
Order Number: DWC-3741
Date of Order: 12/19/2014
Action Taken: Fined $35,000
Violation: Failed to timely act on a properly completed medical bill; Failed to submit accurate medical EDI bills to TDI-DWC

Great Midwest Insurance Company of Houston
Order Number: DWC-3740
Date of Order: 12/19/2014
Action Taken: Fined $3,400
Violation: Failed to timely pay income benefits to injured employee; Failed to accurately notify TDI-DWC and injured employee of actions taken on a claim

Kinnison, David Wayne D.C. of North Richland Hills
Order Number: DWC-3739
Date of Order: 12/19/2014
Action Taken: Fined $1,000; Cannot apply or reapply for certification as a designated doctor until after March 31, 2017
Violation: Failed to timely respond to request for clarification

Liberty Insurance Corporation of Irving
Order Number: DWC-3697
Date of Order: 12/2/2014
Action Taken: Fined $9,000
Violation: Failed to pay benefits in accordance with designated doctor’s opinion; Failed to timely comply with TDI-DWC decision and order

Medical Center of Arlington of Arlington
Order Number: DWC-3731
Date of Order: 12/18/2014
Action Taken: Fined $4,000
Violation: Improperly pursued a private claim against an employer; Failed to comply with an Order to Produce

New Hampshire Insurance Company of New York, NY
Order Number: DWC-3698
Date of Order: 12/2/2014
Action Taken: Fined $89,000
Violation: Failed to timely submit accurate medical bill and payment EDI records to TDI-DWC; Failed to timely pay income benefits to injured employee; Failed to take action on a properly completed medical bill; Failed to timely process a travel reimbursement request; Failed to timely process a completed medical bill; Failed to timely submit accurate medical EDI records to TDI-DWC; Failed to timely provide information requested by an injured employee; Failed to timely pay attorney’s fees; Failed to provide list of all injured worker injuries determined to be compensable by TDI-DWC or as accepted as compensable by insurance carrier; Failed to timely pay in accordance with a Benefit Dispute Agreement; Failed to report to TDI-DWC the initial payment of income benefits

Phoenix Insurance Company of Hartford, CT
Order Number: DWC-3732
Date of Order: 12/18/2014
Action Taken: Fined $5,750
Violation: Failed to timely pay temporary income benefits to injured employee; Failed to accurately report income benefits data to TDI-DWC

Prentice, Kevin Lee D.C. of Lewisville
Order Number: DWC-3694
Date of Order: 12/2/2014
Action Taken: Fined $2,000
Violation: Failed to timely file and/or accurately complete TDI-DWC forms, reports or records

Property and Casualty Insurance Company of Hartford of Hartford, CT
Order Number: DWC-3749
Date of Order: 12/22/2014
Action Taken: Fined $8,000
Violation: Failed to timely pay benefits in accordance with designated doctor’s opinion

Protective Insurance Company of Carmel, IN
Order Number: DWC-3699
Date of Order: 12/2/2014
Action Taken: Fined $9,000
Violation: Failed to timely pay temporary income benefits to injured employee; Failed to timely notify TDI-DWC and injured employee of actions taken on a claim

Quiroz, Juan Francisco M.D. of Sunnyvale
Order Number: DWC-3690
Date of Order: 12/1/2014
Action Taken: Fined $750
Violation: Failed to timely file and/or accurately complete TDI-DWC forms, reports or records

SeaBright Insurance Company of Seattle, WA
Order Number: DWC-3744
Date of Order: 12/19/2014
Action Taken: Fined $16,000
Violation: Failed to timely act on a properly completed medical bill; Failed to timely submit accurate medical EDI records to TDI-DWC

Sentry Casualty Company of Stevens Point, WI
Order Number: DWC-3745
Date of Order: 12/19/2014
Action Taken: Fined $4,400
Violation: Failed to timely pay temporary income benefits to injured employee; Failed to accurately report benefits and payment data to TDI-DWC

Starr Indemnity & Liability Company of New York, NY
Order Number: DWC-3751
Date of Order: 12/23/2014
Action Taken: Fined $5,500
Violation: Failed to timely pay income benefits to injured employee; Failed to accurately notify TDI-DWC and injured employee of actions taken on a claim

Technology Insurance Company of New York, NY
Order Number: DWC-3733
Date of Order: 12/18/2014
Action Taken: Fined $9,000
Violation: Failed to timely pay temporary income benefits to injured employee; Failed to timely notify TDI-DWC and injured employee of actions taken on a claim

Texas Mutual Insurance Company of Austin
Order Number: DWC-3746
Date of Order: 12/19/2014
Action Taken: Fined $12,000
Violation: Failed to timely comply with a commissioner’s order to produce information; Failed to notify the division of refusal to pay a medical bill; Failed to timely pay impairment benefits based on a designated doctor’s opinion

Texas Public School Workers’ Compensation Project of Plano
Order Number: DWC-3700
Date of Order: 12/2/2014
Action Taken: Fined $7,500
Violation: Failed to timely pay income benefits to injured employee; Failed to timely notify TDI-DWC and injured employee of actions taken on a claim

Twin City Fire Insurance Company of Hartford, CT
Order Number: DWC-3701
Date of Order: 12/2/2014
Action Taken: Fined $3,000
Violation: Failed to comply with TDI-DWC order

Valley Forge Insurance Company of Chicago, IL
Order Number: DWC-3748
Date of Order: 12/19/2014
Action Taken: Fined $6,000
Violation: Failed to timely pay temporary income benefits to injured employee; Failed to accurately report initial temporary income data to TDI-DWC

Zurich American Insurance Company of Schaumburg, IL
Order Number: DWC-3712
Date of Order: 12/11/2014
Action Taken: Fined $3,400
Violation: Failed to timely issue payment to health care provider

Source: TDI-DWC

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