TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS' COMPENSATION
All System Participants
2/2/2009
Complaints Received in CY 2008
1200 1000 791 800 600 400 200 0 Jan '08 Feb '08 Mar '08 Apr '08 May '08 Jun '08 Jul '08 Aug '08 Sep '08 Oct '08 Nov '08 Dec '08 972 965 981 709 735 630 577 588 471 467 722
Complaints Received in CY 2008 by Category
3000 2500 2000 1500 1000 500 0
2554 2265
828 385 19
ATTENDANCE ACCURATE DATA SUBMISSION COMMUNICATION
213
FRAUD
329
MEDICAL BILL/REFUND PROCESSING INDEMNITY BENEFIT DELIVERY MEDICAL REIMBURSEMENT
574 134
PROCESSING PREAUTH/CONCURRENT REVIEW
579 32
REQUESTING PREAUTH/CONCURRENT REVIEW QUALITY OF CARE
Indemnity Benefit Delivery Category
200 150 100 50 0 D565 D566 D567 D568 D569
Medical Bill/Refund Processing Category
1000 800
157 94 64 11 3
834
887
600 400 200 0 D620 D621 D622 D623 D624 D625 D626 D627
OTHER
333 38 13 128 8 24
D565: Not initiating indemnity benefits timely D566: Not continuing indemnity benefits timely D567: Not paying the correct indemnity benefit rate D568: Not complying with indemnity orders/agreements D569: Not paying interest on income benefits
D620: Not timely responding to medical bills & requests for reconsideration D621: Not timely responding to requests for out of pocket expenses D622: Improper denials D623: Insufficient reason for denial D624: Insufficient reason for denial based on peer review D625: Not complying with medical orders/agreements D626: Not paying interest on medical bills D627: Delay in responding to medical bill refund/reimbursement requests
Based on Data Extracted from CIS on 2/2/2009
System Monitoring & Oversight - Complaint Data
PAGE 1 OF 2
All System Participants
Complaints Received in CY 2008...."Closed" Status
4500 4000 3500 3000 2500 2000 1500 1000 500 0
4392
1505 916 0 F10 694
F11
F20
F40
F90
F40: Inquiry Only F90: Record Only/Referral
F10: Complaint (Prior to 9/1/1993) F11: Justified Complaints
F20: Unjustified Complaints
Breakdown of Closed Justified Complaints Received in CY 2008
500 400 300 200 100 0
56 9 50 5 50 0 56 5 10 5 56 6 60 1 62 2 62 5 64 67 0 68 0 D 65 0 66 2 71 3 50 3 56 8 62 0 62 3 D D D D D D D D D D D D D D D D D D D 90
446
72 2
101 2 8 4 2 15 15 18 4 20 8 1 1 5
47
88
57
CY 2008 COMPLAINANT DATA
Top Referring Field Offices
400 350 300 250 200 150 100 50 0
192 180 337 290 246
DWC809 - EL PASO FIELD OFFICE DWC819 SAN ANTONIO FIELD OFFICE DWC820 TYLER FIELD OFFICE DWC824 WESLACO FIELD OFFICE DWC807 DALLAS FIELD OFFICE
Complainant Type 3000 2500 2000 1500 1000 500 0 2490 1212 209 Employer Provider Injured Employee 340 Attorney 246 Insurance Company
PAGE 2 OF 2
Based on Data Extracted from CIS on 2/2/2009
System Monitoring & Oversight - Complaint Data