Texas Workers’ Comp Div. Assesses $285K in Fines June – Oct. 2008

The Texas Department of Insurance Division of Workers’ Compensation (TDI-DWC) from June through October 2008 assessed administrative penalties totaling $285,775 in disciplinary orders issued by Commissioner of Workers’ Compensation Rod Bordelon.

Commissioner’s orders are subject to appeal to state district court within 30 days after being issued.

TDI-DWC Disciplinary Orders June – October 2008:

Ace American Insurance Company, Philadelphia, PA
Order No.: DWC-08-0074
Date of Order: Aug. 20, 2008
Action Taken: Fined $17,500
Violation(s): Failure to timely pay an Independent Review Organization (IRO) fee; improper denial of a preauthorized medical service; improper denial of a medical bill.

Ace American Insurance Company, Philadelphia, PA
Order No.: DWC-08-0075
Date of Order: Aug. 20, 2008
Action Taken: Fined $14,875
Violation(s): Failure to timely initiate temporary income benefits (TIBs) payments.

Ace American Insurance Company, Ace Fire Underwriters Insurance Company, Ace Indemnity Insurance Company, Ace Property and Casualty Insurance Company, Bankers Standard Fire and Marine Company, Bankers Standard Insurance Company, Century Insurance Company, Indemnity Insurance Company of North America, Insurance Company of North America, Pacific Employers Insurance Company of Philadelphia, PA
Order No.: DWC-08-0081
Date of Order: Sept. 4, 2008
Action Taken: Fined $50,000
Violation(s): Failure to timely provide information requested by TDI-DWC.

American Casualty Company of Reading, Pennsylvania of Chicago, IL
Order No.: DWC-08-0056
Date of Order: June 10, 2008
Action Taken: Fined $2,950
Violation(s): Late payment of temporary income benefits (TIBs).

American Contractors Insurance Group of Dallas
Order No.: DWC-08-0069
Date of Order: Aug. 20, 2008
Action Taken: Fined $5,000
Violation(s): Failure to pay, reduce, deny or determine to audit the health care provider’s claim in a timely manner; failure to comply with an order or decision of the commissioner (two instances).

American Zurich Insurance Company of Schaumburg, IL
Order No.: DWC-08-0050
Date of Order: June 6, 2008
Action Taken: Fined $3,000
Violation(s): Failure to take final action on a medical bill within 45 days of receipt (two instances).

Howard T. Douglas, M.D. of Irving
Order No.: DWC-08-0080
Date of Order: Aug. 29, 2008
Action Taken: Fined $10,000
Violation(s): Failure to respond to a request for letter of clarification within five days of receipt; failure to timely file a Report of Medical Evaluation with TDI-DWC, the injured employee, the injured employee’s representative, and the insurance carrier (three instances).

Employers General Insurance Company of Rock Island, IL
Order No.: DWC-08-0091
Date of Order: Oct. 16, 2008
Action Taken: Fined $30,000
Violation(s): Inappropriate denials of payment for preauthorized services (81 instances); and inappropriate use of denial code to deny payment for services not requiring preauthorization (35 instances), as found during a medical billing and preauthorization processing audit.

Employers Mutual Casualty Company of Des Moines, IA
Order No.: DWC-08-0055
Date of Order: June 10, 2008
Action Taken: Fined $20,000
Violation(s): Improper denial of preauthorized medical services.

Sameer A. Fino, M.D., of Mesquite
Order No.: DWC-08-0054
Date of Order: June 10, 2008
Action Taken: Fined $1,250
Violation(s): Failure to assign a specific date at which maximum medical improvement (MMI) was reached; failure to state an MMI on a Report of Medical Evaluation or to sign the form; failure to comply with a rule of the workers’ compensation commissioner; failure to timely file a Report of Medical Evaluation.

Hartford Casualty Insurance Company, Hartford Insurance Company of the Midwest, Twin City Fire Insurance Company of Hartford, CT
Order No.: DWC-08-0052
Date of Order: June 6, 2008
Action Taken: Fined $21,000
Violation(s): Failure to pay income benefits weekly as and when they accrue without order from the workers’ compensation commissioner; failure to pay supplemental income benefits (SIBs) in a timely manner; failure to continue to pay benefits promptly; failure to pay interest on any accrued but unpaid income benefits; failure to pay SIBS in the correct amount; failure to enclose a copy of the Application for Supplemental Income Benefits with the SIBs payment; and failure to meet the 95 percent compliance standard for timeliness of payment of SIBs, payment of SIBs at the proper rate, correct payment of interest when owed, and timeliness of sending Application for Supplemental Income Benefits.

Hartford Casualty Insurance Company, Hartford Insurance Company of the Midwest, Twin City Fire Insurance Company of Hartford, CT
Order No.: DWC-08-0053
Date of Order: June 6, 2008
Action Taken: Fined $20,000
Violation(s): Failure to make an appropriate payment of charges for medical services; failure to pay for services that were preauthorized; failure to include a correct exception code; failure to contact the requestor or employee within three working days of receipt of a request for preauthorization; and failure to meet the 95 percent compliance standard for timeliness of payments of SIBs, payment of SIBs at the proper rate, correct payment of interest when owed, and timeliness of sending the Application for Supplemental Income Benefits.

Houston Independent School District of Houston
Order No.: DWC-08-0090
Date of Order: Oct. 16, 2008
Action Taken: Fined $4,000
Violation(s): Improper denial of preauthorized services (four instances).

Indemnity Insurance Company of North America of Philadelphia, PA
Order No.: DWC-08-0073
Date of Order: Aug. 20, 2008
Action Taken: Fined $18,000
Violation(s): Failure to reimburse health care provider according to the least of maximum allowable reimbursement (MAR) or the health care provider’s usual and customary charge; failure to pay for medical services that were preauthorized; failure to take final action on a medical bill within 45 days of receipt.

Irving Independent School District of Irving
Order No.: DWC-08-0071
Date of Order: August 20, 2008
Action Taken: Fined $5,000
Violation(s): Failure to timely take action on a medical bill; failure to timely submit information; failure to meet the 95 percent compliance standard.

Lowes Home Centers, Inc. of Mooresville, NC
Order No.: DWC-08-0087
Date of Order: Oct. 16, 2008
Action Taken: Fined $1,500
Violation(s): Failure to take final action on a medical bill within 45 days of receipt.

Old Republic Insurance Company of Greensburg, PA
Order No.: DWC-08-0072
Date of Order: Aug. 20, 2008
Action Taken: Fined $18,000
Violation(s): Failure to timely comply with an order on decision of the workers’ compensation commissioner; failure to timely pay an IRO fee; failure to take final action on a medical bill within 45 days of receipt (two instances).

OneBeacon Insurance Company of Boston, MA
Order No.: DWC-08-0086
Date of Order: Oct. 16, 2008
Action Taken: Fined $18,000
Violation(s): Inappropriate denials of payment for preauthorized services (56 instances); and inappropriate use of denial code to deny payment for services not requiring preauthorization (15 instances), as found during a medical billing and preauthorization processing audit.
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Pacific Employer’s Insurance Company of Philadelphia, PA
Order No.: DWC-08-0076
Date of Order: Aug. 20, 2008
Action Taken: Fined $1,500
Violation(s): Improper denial of a medical bill.

Sompo Japan Insurance Company of America of New York City, NY
Order No.: DWC-08-0088
Date of Order: Oct. 16, 2008
Action Taken: Fined $15,000
Violation(s): Failure to provide an on-site safety visit or other appropriate accident prevention services on a periodic basis and at least every 12 months to policyholders with a premium of $25,000 or more.

Universal Underwriters of Texas Insurance Company of Overland Park, KS
Order No.: DWC-08-0089
Date of Order: Oct. 16, 2008
Action Taken: Fined $2,200
Violation(s): Failure to comply with an order or decision of the workers’ compensation commissioner.

Virginia Surety Company, Inc. of Chicago, IL
Order No.: DWC-08-0070
Date of Order: Aug. 20, 2008
Action Taken: Fined $7,000
Violation(s): Failure to comply with an order or decision of the workers’ compensation commissioner.

Source: Texas Department of Insurance Division of Workers’ Compensation, www.tdi.state.tx.us/wc/index.html