Opinion ID: 894529
Heading Depth: 2
Heading Rank: 1

Heading: TWCC's Audit Authority

Text: TWCC maintains that the auditing powers granted it by the Labor Code are separate and distinct from the auditing process established by the Dispute and Audit Rules. TWCC claims that it conducts its own independent reviews and audits of health care providers and insurance carriers and that the Dispute and Audit Rules relate to a different matterthe review and processing of medical bills. TWCC argues that the rules set out a fair and balanced approach to the payment of medical bills by specifying each party's responsibilities and limitations within the workers' compensation system and therefore do not delegate TWCC's auditing authority. We agree. The Labor Code vests TWCC with the power to audit insurance carriers and health care providers. See Tex. Lab.Code §§ 413.001-.054. TWCC must maintain a division of medical review to monitor workers' compensation participants and ensure they comply with the rules adopted by the agency. Id. § 413.002(a)-(b). Additionally, TWCC is required to promulgate rules to establish programs for the systematic monitoring of the necessity of treatments rendered and fees charged and paid for medical treatments or services. Id. § 413.013(2). TWCC must also establish rules for the review and audit of payments carriers make to providers to ensure that both parties comply with the medical policies and fee guidelines established by the agency. Id. § 413.015(b). The Dispute and Audit Rules, on the other hand, permit insurance carriers to retrospectively review medical bills to gather additional information for purposes of paying or denying a medical claim. 28 Tex. Admin. Code § 133.301. This process aims to provide necessary information so that carriers may analyze fees charged and check medical necessity prior to making reimbursements. The Dispute and Audit Rules set out in great detail the procedures carriers must follow when conducting onsite audits. Id. §§ 133.302-.303. Under the framework of TWCC's rules, insurance carriers have no power to set public policy or promulgate rules to accomplish that policy. See FM Props., 22 S.W.3d at 873, 880; Boll Weevil, 952 S.W.2d at 470-71. Moreover, the Dispute and Audit Rules do not give carriers the authority to ascertain the conditions upon which existing laws will apply. See FM Props., 22 S.W.3d at 873, 880; Higginbotham, 143 S.W.2d at 87. Instead, carriers must follow the policy mandated by the Legislature in the Labor Code and executed by TWCC in the Dispute and Audit Rules. Independent of the audit process defined by the rules, TWCC reviews and audits carriers and providers to monitor their activities and ensure compliance with the agency's guidelines. Tex. Lab.Code §§ 413.002, 413.015. In this instance, TWCC retains all the powers delegated to it by the Legislature. Thus, the Dispute and Audit Rules do not delegate TWCC's audit authority to private insurance carriers but are a means for TWCC to fulfill its statutory duties. See City Pub. Serv. Bd., 53 S.W.3d at 315-16; GTE-Southwest, 901 S.W.2d at 407; Lone Star Gas, 844 S.W.2d at 685.