Tuesday, May 8, 2012

Texas: The Clock is Ticking on Legacy Claims

Back in January, my colleague Mark Pew penned a white paper entitled "Legacy Clean Up, Texas Style."  The paper encouraged stake holders in the Texas work comp system to get started on the process of addressing legacy claims in relation to the new closed formulary rules, despite a timeline in the new rules that doesn't require action until early 2013: "Given the potentially extreme physical and psychological addiction associated with these drugs, it is time to get started towards those deadlines. This should make 2012 the 'Year of Legacy Claim Cleanup' in Texas." 

Yesterday, the Insurance Council of Texas (ICT) published a bulletin emphasizing the need for the work comp insurance community to get moving on this issue.  The bulletin reminded stakeholders that "the DWC has urged all involved parties to begin the legacy claims transition process 'much sooner' than the rule's mandated timelines to avoid last minute complications, and to foster timely, manageable prescribing of drugs suitable to each injured employee."   Further, the ICT states that "the DWC is concerned that there are insurance carriers and physicians who may wait until the 'eleventh hour' to begin the transition of legacy claims to the Closed Formulary.  The DWC believes that the delay in transitioning the legacy claims could result in interruption of the delivery of medically appropriate and necessary pharmaceutical benefits." 

This is a diplomatic way of saying, "September 2, 2013 [the day after the closed formulary rules go into effect for all legacy claims] is going to a very complicated day for all of us if we don't get our act together NOW!"

This is serious, folks.  Texas isn't messing around here.  Come September of 2013, if a drug isn't documented as medically necessary, it isn't going to be dispensed (at least, not without a medical interlocutory order).  

If only there were a clear way to deal with these claims...

Good news: DWC actually thought of that!  The rules provide for a mechanism for insurance carriers to engage directly with treating physicians to determine (and clearly document prior to September 1, 2013) the applicability of the closed formulary to each individual legacy claim.  This is a big task and for some carriers/employers, this is going to be a huge project.  So get to work!

And if you're struggling with the issue, let us know.  PRIUM has developed a continuing education module on the topic and we'd be happy to share with anyone that needs help. 

On Twitter @PRIUM1

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