drug therapy for a period of time, and some agreements simply stated that the patient would continue taking an N drug, and the physician and carrier would check back in a year.
The carrier continues to revise the
process based on physician feedback, Mr. Haugaard says. If needed, for example, Texas Mutual could help provide addi- tional support, such as a rehabilitation specialist, although to date that has not come up. “This really has turned into a very
good relationship-enhancing dialogue. This is not us telling doctors what they must do. We know that won’t work,” he said.
Of the peer-to-peer discussions held
so far, a small percentage of physicians opted to wait until closer to the Sept. 1 deadline to decide on a transition plan, while a few were unreceptive to Texas Mutual’s outreach efforts. “We will continue to reach out to pro- viders in order to facilitate the process as much as possible. It is our preference that as many claims as possible are ad- dressed via a letter of agreement instead of through the preauthorization process,” Mr. Haugaard said.
Protective measures Should the physician and carrier remain at odds over a patient’s treatment, the doctor still can prescribe the drug, but would have to document medical neces- sity within the preauthorization request for the prescription.
If the carrier still denies the request, DWC rules include what Mr. Zurek describes as a “fail-safe” mechanism, known as a medical interlocutory order (MIO). The appeal process allows physi- cians to challenge a carrier’s denial and to maintain the status quo while going through a dispute. But Mr. Zurek cautioned that the pro- cess is not meant to be an easy out or a guarantee of approval, just because an insurer declined to grant a physician’s preauthorization request. Upon filing an MIO, physicians must certify that without the N drug, a patient could experience a medical emergency. In addition, “a doctor has to be willing to take this to a [formal] independent
review, and further, if needed,” he said. “I recommend doctors get very familiar with this rule.” Log on to the TMA website at www
.texmed.org/CompFormulary for infor- mation on MIOs.
No one used the MIO process during
the first phase of the closed formulary, Mr. Zurek says. “What this tells us is that if somebody needs the drug, they are getting it; or [physician and carriers] are working it out, and the need to have the DWC intercede hasn’t occurred.” Mr. Zurek acknowledged that any transition can be difficult, and adminis- trative hurdles can sometimes dissuade physicians from participating in the workers’ compensation system. But he noted that all of the 15,000 legacy patients have a doctor caring for them. And by providing a list of ap- proved drugs for physicians to choose from and due-process protections, DWC hopes to minimize any undue difficulties with the closed formulary. The agency also has a process in place to hold insurance carriers account- able for contacting physicians regarding agreement discussions. “What we hope for is that everybody
takes this seriously, and does so early to work through all of the various situa- tions, so on Sept. 1, 2013, the vast ma- jority of injured employees will get the drugs they need without any kind of delay or process restrictions,” Mr. Zurek said.
Dallas charity care program closes amid 1115 waiver negotiations
As Texas moves forward with plans to re- vamp the state’s Medicaid program, the so-called “1115 waiver” program dealt a major setback to a long-running charity care program in the Dallas County area. Leaders of Project Access Dallas
(PAD), a partnership of 2,000 volunteer physicians and dozens of charity com- munity clinics, hospitals, pharmacies, and other health care organizations launched in 2002 — announced that the program will close in 2013 due to an im- passe in funding negotiations under the waiver process.
The 1115 waiver process is playing out differently across the state. The March issue of Texas Medicine will have more in-depth coverage. In December 2011, Texas won ap-
proval from the federal government for a five-year demonstration waiver that al- lows the state to expand Medicaid man- aged care. The goal is to transition to a more coordinated delivery system that improves quality while reducing costs. The waiver preserved some supple- mental federal funding designed to help offset the costs of uncompensated care provided by hospitals or other qualified providers under the Medicaid Upper Payment Limit (UPL) program. It also
Capital Medical Clinic seeking
Board Certified Internist Outpatient Care Only
Interested Candidates please submit your CV to Mr. Pete Hager at
phager@capmedaustin.com February 2013 TEXAS MEDICINE 43
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68