Texas Workers’ Comp Sept. Enforcements Bring Nearly $268K in Fines

The Texas Department of Insurance Division of Workers’ Compensation in September issued nearly $268,000 in fines in disciplinary actions. The orders issued by Commissioner of Workers’ Compensation Rod Bordelon are subject to appeal to state district court within 30 days after being issued.

Final DWC disciplinary orders for September 2010 include:

Ace American Insurance Company of Philadelphia, PA
Order Number: DWC10-0079
Date of Order: 9/16/2010
Order Final In: September
Action Taken: Fined $74,000
Violation: Failed to pay medical costs related to an emergency or treatments/services that require preauthorization when preauthorized; Failed to timely respond to request for preauthorization

Ace American Insurance Company of Philadelphia, PA
Order Number: DWC10-0080
Date of Order: 9/16/2010
Order Final In: September
Action Taken: Fined $147,000
Violation: Failed to comply with decision or order of the TDI-DWC Commissioner; Failed to pay indemnity benefits; Failed to timely pay medical benefits; Failed to pay medical bills according to TDI-DWC Medical Fee Guidelines

Holleman, James F., Jr. D.O. of Tyler
Order Number: DWC10-0078
Date of Order: 9/10/2010
Order Final In: September
Action Taken: Cease and desist from providing health care services in the workers’ compensation system
Violation: Failed to follow current guidelines for evaluation of expected or average return-to-work timeframes; Failed to provide reasonable and necessary care to injured employee; Failed to maintain efficient utilization of health care

Methodist Hospital of Cincinnati, OH
Order Number: DWC10-0083
Date of Order: 9/29/2010
Order Final In: September
Action Taken: Fined $8,000
Violation: Improperly billed an injured employee for workers’ compensation medical services provided

Najera, Raul Abel M.D. of Dallas
Order Number: DWC10-0074
Date of Order: 9/3/2010
Order Final In: September
Action Taken: Fined $2,000
Violation: Failed to file DWC Form-69 in a timely manner; Failed to timely file a narrative report; Failed to timely respond to a Letter of Clarification

Refaeian, Manouchehr M.D. of Austin
Order Number: DWC10-0081
Date of Order: 9/29/2010
Order Final In: September
Action Taken: Fined $20,000; Suspended from Designated Doctor List for six months beginning December 1, 2010; Must attend educational conference on roles and responsibilities of health care providers in workers’ compensation system
Violation: Failed to timely file DWC Form-69 with TDI-DWC (133 instances); Failed to file DWC Form-69 with the carrier via facsimile or electronic transmission (136 instances)

Shanti, Ihsan M.D. of Houston
Order Number: DWC10-0073
Date of Order: 9/3/2010
Order Final In: September
Action Taken: Withdrawal from practicing in the Texas workers’ compensation system
Violation: License to practice medicine revoked, suspended or not renewed by appropriate licensing or certification authority; Sought payment for medical services which were not rendered

Southwestern Bell Telephone, LP of Dallas
Order Number: DWC10-0072
Date of Order: 9/3/2010
Order Final In: September
Action Taken: Fined $3,500
Violation: Failed to take final action on a medical bill not later than the 45th day after the date complete medical bill received; Violated administrative rules by providing notice disputing future medical benefits

Standard Fire Insurance Company of Hartford, CT
Order Number: DWC10-0071
Date of Order: 9/3/2010
Order Final In: September
Action Taken: Fined $8,000
Violation: Failed to timely issue initial Temporary Income Benefits (TIBs); Failed to timely report initial TIBs payments; Failed to accurately report First Dates of Disability

Voge, Victoria M. M.D. of Round Rock
Order Number: DWC10-0082
Date of Order: 9/29/2010
Order Final In: September
Action Taken: Fined $5,000; Must maintain current appointment location matrix for six months; Must attend educational conference on roles and responsibilities of health care providers in workers’ compensation system
Violation: Failed to file DWC Form-69 in timely manner; Failed to timely file DWC Form-69 with insurance carrier; Failed to notify TDI-DWC with time and date of rescheduled appointment

Source: TDI-DWC