The Texas Division of Workers’ Compensation has released its official 2024 rankings of workers’ compensation insurance carriers, and the results are bad news for a handful of insurers.

Catherine Montgomery

The Texas Labor Code requires the DWC to conduct assessments on insurance carriers and health care providers every two years to identify those that “adversely impact the workers’ compensation system” and may need extra oversight.

This information is worth having for Texas providers treating injured workers. Part of the state’s assessment criteria involves the timely processing of providers’ bills and appeals of improper payment denials and reductions.

Performance-based oversight

Texas Labor Code Section 402.075(c) mandates that selected providers and carriers are regularly assessed for compliance with the most critical billing and payment requirements. These assessments have potential consequences. As Section 402.075(c) states:

The division shall examine overall compliance records and dispute resolution and complaint resolution practices to identify insurance carriers and health care providers who adversely impact the workers' compensation system and who may require enhanced regulatory oversight.

Performance-based oversight assesses insurance carriers' performance in five specific areas, three of which are of particular concern to providers who treat Texas injured workers:

• Timely payment of temporary income benefits.
• Timely reporting of initial payment of TIBs to the DWC (not factored into ranking).
• Timeliness of processing initial medical bills.
• Timeliness of processing requests for reconsideration of medical bills.
• Timeliness of submission of the EDI medical data to the DWC.

Carriers self-report data to the DWC to assess these five areas. For the 2024 rankings, the DWC looked at data submitted from Jan. 1, 2024, to June 30, 2024.

The Texas PBO rating system assigns up to 30 out of 100 points to the timely processing of providers’ initial medical bills and up to 10 points to the timely processing of requests to reconsider improper adjustments or denials.

In other words, timely bill and appeal processing is a significant factor in a carrier’s ranking, as it should be.

Based on those assessments, the DWC places insurance carriers into high, average or poor performance categories. Any carrier that fails to score at least 80 points is considered a poor performer.

Poor performers

The complete list of all three tiers is available here. Providers should consider these rankings when deciding whether to treat injured workers covered by a carrier.

Only four carriers, all insurance companies, were rated poor for 2024, as shown below:

• AmTrust.
• Berkshire Hathaway.
• Redwood Fire & Casualty.
• Tri-State Insurance Co. of Minnesota.

That AmTrust and Berkshire Hathaway would rank poor doesn’t exactly surprise daisyBill; in years past, daisyBill has submitted formal audit complaints to the California Division of Workers’ Compensation for tens of thousands of violations by both of these insurers.

Unfortunately, California rarely imposes consequences for noncompliant carriers. The Texas DWC, however, pledges to “focus oversight efforts on insurance carriers found to be poor performers in PBO.”

Moreover, Texas Administrative Code Section 180.26(e) directs the DWC to consider PBO ratings when deciding how severely to sanction a carrier found to engage in regulatory violations. Sanctions can include fines, suspensions and more.

Texas providers, take note: If an insurance carrier is found to be underperforming in its legal obligations to providers and injured workers, it may be a bright red flag regarding your practice’s ability to get paid quickly and correctly for treating those carriers’ covered workers.

Catherine Montgomery is the co-founder and CEO of daisyBill, a provider of workers' comp end-to-end revenue cycle management software. This post appears with permission.