2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.011. Reimbursement Policies and Guidelines; Treatment Guidelines and Protocols

Sec. 413.011.  REIMBURSEMENT POLICIES AND GUIDELINES; TREATMENT GUIDELINES AND PROTOCOLS.  (a)  The commissioner shall adopt health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems with minimal modifications to those reimbursement methodologies as necessary to meet occupational injury requirements.  To achieve standardization, the commissioner shall adopt the most current reimbursement methodologies, models, and values or weights used by the federal Centers for Medicare and Medicaid Services, including applicable payment policies relating to coding, billing, and reporting, and may modify documentation requirements as necessary to meet the requirements of Section 413.053.
(b)  In determining the appropriate fees, the commissioner shall also develop one or more conversion factors or other payment adjustment factors taking into account economic indicators in health care and the requirements of Subsection (d).  The commissioner shall also provide for reasonable fees for the evaluation and management of care as required by Section 408.025(c) and commissioner rules.  This section does not adopt the Medicare fee schedule, and the commissioner may not adopt conversion factors or other payment adjustment factors based solely on those factors as developed by the federal Centers for Medicare and Medicaid Services.
(c)  This section may not be interpreted in a manner that would discriminate in the amount or method of payment or reimbursement for services in a manner prohibited by Section 1451.104, Insurance Code, or as restricting the ability of chiropractors to serve as treating doctors as authorized by this subtitle.  The commissioner shall also develop guidelines relating to fees charged or paid for providing expert testimony relating to an issue arising under this subtitle.
(d)  Fee guidelines must be fair and reasonable and designed to ensure the quality of medical care and to achieve effective medical cost control.  The guidelines may not provide for payment of a fee in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual's behalf.  The commissioner shall consider the increased security of payment afforded by this subtitle in establishing the fee guidelines.
(d-1)  Expired.
(d-2)  Expired.
(d-3)  Expired.
(d-4)  Notwithstanding this section or any other provision of this title, an insurance carrier, an insurance carrier's authorized agent, or a network certified under Chapter 1305, Insurance Code, arranging for non-network services or out-of-network services under Section 1305.006, Insurance Code, may continue to contract with a health care provider to secure health care for an injured employee for fees that exceed the fees adopted by the division under this section.
(d-5)  The commissioner and the commissioner of insurance may adopt rules as necessary to implement this section.
(d-6)  Expired.
(e)  The commissioner by rule shall adopt treatment guidelines and return-to-work guidelines and may adopt individual treatment protocols.  Treatment guidelines and protocols must be evidence-based, scientifically valid, and outcome-focused and designed to reduce excessive or inappropriate medical care while safeguarding necessary medical care.  Treatment may not be denied solely on the basis that the treatment for the compensable injury in question is not specifically addressed by the treatment guidelines.
(f)  In addition to complying with the requirements of Subsection (e), medical policies or guidelines adopted by the commissioner must be:
(1)  designed to ensure the quality of medical care and to achieve effective medical cost control;
(2)  designed to enhance a timely and appropriate return to work; and
(3)  consistent with Sections 413.013, 413.020, 413.052, and 413.053.
(g)  The commissioner may adopt rules relating to disability management that are designed to promote appropriate health care at the earliest opportunity after the injury to maximize injury healing and improve stay-at-work and return-to-work outcomes through appropriate management of work-related injuries or conditions.  The commissioner by rule may identify claims in which application of disability management activities is required and prescribe at what point in the claim process a treatment plan is required.  The determination may be based on any factor considered relevant by the commissioner.  Rules adopted under this subsection do not apply to claims subject to workers' compensation health care networks under Chapter 1305, Insurance Code.
(h)  A dispute involving a treatment plan required under Subsection (g) may be appealed to an independent review organization in the manner described by Section 413.031.
(i)  The division shall examine whether injured employees have reasonable access to surgically implanted, inserted, or otherwise applied devices or tissues and investigate whether reimbursement rates or any other barriers exist that reduce the ability of an injured employee to access those medical needs.  The division shall recommend to the legislature any statutory changes necessary to ensure appropriate access to those medical needs.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 6.02, eff. June 17, 2001;  Acts 2003, 78th Leg., ch. 962, Sec. 1, 2, eff. June 20, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.233, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 1177 (H.B. 473), Sec. 2, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 1177 (H.B. 473), Sec. 2, eff. January 1, 2011.