Austin, TX – Commissioner of Workers’ Compensation Ryan Brannan recently announced final disciplinary actions taken by the Division of Workers’ Compensation (DWC).
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 $1,774,345 for system participants. The penalties include $1,658,245 in fines ordered for insurance carriers, $65,600 in fines ordered for health care providers, $49,500 in fines ordered for other entities and $1,000 in fines ordered for employers.
Violations of the Texas Labor Code by insurance carriers cited in recent orders include failure to timely pay income benefits to an injured employee, failure 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 failure to document an injury to justify ongoing treatments and medications and failure to timely file and/or accurately complete DWC forms, reports or records. Violations cited in orders naming other entities include adjusters performing utilization reviews and issuing medical necessity denials without allowing health care providers a reasonable opportunity to discuss with a medical doctor.
Summaries of the orders follow.
American Zurich Insurance Company of Schaumburg, IL
Order Number: DWC-3548
Date of Order: 9/18/2014
Action Taken: Fined $15,500
Violation: Failed to timely and accurately notify TDI-DWC and injured employee of actions taken on a claim; Failed to timely pay benefits based on opinion of designated doctor during pendency of dispute; Failed to timely act on a properly completed medical bill; ; failed to properly submit request for designated doctor examination
Burgesser, Mary Francis M.D. of Brookfield, WI
Order Number: DWC-3557
Date of Order: 9/23/2014
Action Taken: Permanently removed from Texas workers’ compensation system as a health care provider
Violation: Provided treatments and/or evaluations substantially different from those found by commissioner to be fair and reasonable which were based on inadequate medical record documentation
Hartford Insurance Company of the Midwest of Hartford, CT
Order Number: DWC-3534
Date of Order: 9/16/2014
Action Taken: Fined $40,000
Violation: Failed to pay income benefits in accordance with designated doctors report; Violated and/or failed or refused to comply with commissioner rule or a provision of Texas Workers’ Compensation Act
Holland, Christine Westmoreland M.D. of Decatur
Order Number: DWC-3523
Date of Order: 9/9/2014
Action Taken: Fined $2,000
Violation: Improperly billed an injured employee for workers’ compensation medical services provided
Marshall, C. Perry M.D, of Tyler
Order Number: DWC-3521
Date of Order: 9/9/2014
Action Taken: Fined $7,500
Violation: Failed to timely file and/or accurately complete TDI-DWC forms, reports or records
National Interstate Insurance Company of Richfield, OH
Order Number: DWC-3524
Date of Order: 9/9/2014
Action Taken: Fined $5,000
Violation: Failed to timely pay income benefits to injured employee based on opinion of designated doctor during pendency of dispute
Safety National Casualty Corporation of St. Louis, MO
Order Number: DWC-3531
Date of Order: 9/15/2014
Action Taken: Fined $1,000
Violation: Failed to timely comply with a decision of the commissioner
Siebenaler, Frank J., Jr., D.C. of Austin
Order Number: DWC-3477
Date of Order: 9/9/2014
Action Taken: Fined $1,000
Violation: Submitted information to TDI-DWC that misrepresented an accurate and/or consistent certification date for results of designated doctor examination
The Standard Fire Insurance Company of Hartford, CT
Order Number: DWC-3525
Date of Order: 9/9/2014
Action Taken: Fined $1,500
Violation: Failed to properly submit request for designated doctor examination
The Travelers Indemnity Company of Hartford, CT
Order Number: DWC-3533
Date of Order: 9/16/2014
Action Taken: Fined $11,500
Violation: Failed to issue timely payment to health care provider; Failed to timely act on request for reconsideration
XL Specialty Insurance Company of Stamford, CT
Order Number: DWC-3526
Date of Order: 9/9/2014
Action Taken: Fined $8,500
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; Failed to timely report initial payment of indemnity benefits to TDI-DWC; Failed to timely act on a properly completed medical bill.
Zurich American Insurance Company of Schaumburg, IL
Order Number: DWC-3547
Date of Order: 9/18/2014
Action Taken: Fined $5,500
Violation: Failed to use TDI-DWC’s adopted medical fee guidelines for reimbursement of professional medical service
Source: TDI-DWC