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 and health care providers in the workers’ compensation system. Beginning January 1, 2015, through May 31, 2015, the Commissioner of Workers’ Compensation has ordered administrative penalties totaling $803,500 for system participants. The penalties include $588,300 in fines ordered for insurance carriers, $169,700 in fines ordered for health care providers, and $45,500 in fines ordered for other entities.
Violations of the Texas Labor Code by insurance carriers cited in recent orders include failure to accurately and timely pay benefits ordered to an injured employee, failure to accurately and timely notify DWC of termination of benefits, and failure to pay benefits in accordance with a designated doctor examination. Violations cited in orders naming health care providers include improper billing of medical services to an injured employee; issuing improper, unreasonable, or medically unnecessary treatment or medical services to an injured employee; and failure to timely file and/or accurately complete DWC forms, reports, or records. Violations cited in orders naming other entities include failure to timely respond to DWC when ordered to produce requested documents.
Summaries of the orders:
Ace American Insurance Company of Wilmington, DE
Order Number: DWC-3964
Date of Order: 5/15/2015
Action Taken: Fined $6,000; Claims adjuster must complete additional continuing education hours specified by TDI-DWC
Violation: Refused to accept medical bills submitted electronically by health care providers
Ace American Insurance Company of Wilmington, DE
Order Number: DWC-3966
Date of Order: 5/15/2015
Action Taken: Fined $16,000
Violation: Failed to pay accrued and unpaid income benefits within five days of filing its appeal; Failed to contact its policyholder within 7 days of a work-related fatality
Dunn, Thomas P.T. of Bellaire
Order Number: DWC-3973
Date of Order: 5/19/2015
Action Taken: Fined $50,000; Agrees to cease participation in the Texas workers’ compensation system and to not receive direct or indirect renumeration from the Texas Workers’ Compensation System
Violation: Improperly billed for services provided to injured employees
Great Midwest Insurance Company of Houston
Order Number: DWC-3946
Date of Order: 5/6/2015
Action Taken: Fined $1,500
Violation: Failed to timely act on a request for preauthorization of health care services for injured employee
Indemnity Insurance Company of North America of Philadelphia, PA
Order Number: DWC-3945
Date of Order: 5/6/2015
Action Taken: Fined $9,000
Violation: Failed to timely pay benefits to injured employee based on opinion of designated doctor
Indemnity Insurance Company of North America of Philadelphia
Order Number: DWC-3976
Date of Order: 5/22/2015
Action Taken: Fined $6,000
Violation: Failed to timely pay income benefits to injured employee; Failed to pay benefits based on opinion of designate doctor during pendency of dispute
Indemnity Insurance Company of North America of Phladelphia, PA
Order Number: DWC-3972
Date of Order: 5/19/2015
Action Taken: Fined $49,000
Violation: Failed to accurately pay lifetime income benefits and death benefits; Failed to provide accurate and timely claims data to the division; Failed to contact its policyholder within 7 days of a work-related fatality
Key, James David, Sr., M.D. of Brownsville
Order Number: DWC-3971
Date of Order: 5/19/2015
Action Taken: Fined $75,000; Must not participate in treating or examining injured employees covered in the Texas workers’ compensation system and/or consult with other physicians regarding injured employees in the system; Cannot receive direct or indirect remuneration from the Texas workers’ compensation system
Violation: Improperly billed for services provided to injured employees
Liberty Mutual Insurance Company of Plymouth Meeting, PA
Order Number: DWC-3947
Date of Order: 5/6/2015
Action Taken: Fined $2,000
Violation: Prospectively denied future medical benefits for injured employee
Old Republic Insurance Company of Greensburg, PA
Order Number: DWC-3983
Date of Order: 5/26/2015
Action Taken: Fined $5,000
Violation: Failed to timely pay income benefits to injured employee; Failed to pay benefits based on opinion of designated doctor during pendency of dispute
Smith, Stephen Lynn D.O. of Fredericksburg
Order Number: DWC-3948
Date of Order: 5/6/2015
Action Taken: Fined $2,000
Violation: Used unprofessional and inappropriate language in a document directed at a workers’ compensation system participant
State Farm Fire and Casualty Company of Bloomington, IL
Order Number: DWC-3960
Date of Order: 5/12/2015
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; Failed to timely report initial payment of benefits to TDI-DWC
The Travelers Indemnity Company of Hartford, CT
Order Number: DWC-3965
Date of Order: 5/15/2015
Action Taken: Fined $500
Violation: Failed to provide sufficient explanation for reduction or denial of a medical bill
Youngblood, Tonya Joyce M.D. of Ennis
Order Number: DWC-3982
Date of Order: 5/26/2015
Action Taken: Fined $2,000; Must complete additional continuing education hours
Violation: Submitted a medical bill for services that were not performed and were not in accordance with applicable Medicare billing policies
Source: TDI-DWC