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At a Glance:
Medical Benefit Review and Audit

§ 134.900

Medical Benefit Review and Audit

(a) The division of medical review (the division) shall review and audit medical services, to include, but not be limited to:

(1) treatments administered;

(2) services provided;

(3) fees charged;

(4) payments made for medical treatment or services provided to injured employees; and

(5) compliance with other commission rules regulating health care.

(b) The division may conduct a review or audit at the office of an insurance carrier, third party administrator, audit company, health care provider, or at any other appropriate location as determined by the division.

(c) The division shall notify, in writing, the person or entity whose documents are to be reviewed and audited, stating when the review and audit will be performed and the commission employee to contact.

(d) The division shall be granted access to documents and to information regarding health care treatment; fees charged; or payments made, modified, or denied. Pursuant to law, failure or refusal to comply with a division request or order for any information is an administrative violation subject to penalty as provided by the Act.

(e) The person or entity being reviewed or audited by the division shall furnish division personnel, for the duration of the review and audit, with:

(1) a contact person to answer questions and respond to the needs of division staff;

(2) office space;

(3) access to a copy machine; and

(4) access to a telephone.

(f) The commission shall charge a reasonable administrative fee, set in accordance with Administrative Procedure 5, for the review and audit conducted under this rule.

(g) The intensity of review and audit for compliance with medical policies and fee guidelines shall be increased as necessary to induce compliance by the health care provider who has established practices and patterns in medical charges or treatments inconsistent with medical policies and guidelines established by the commission.

(h) Reports of all probable violations of law and commission rules found during a review and audit shall be forwarded to the division of compliance and practices.

The provisions of this § 134.900 adopted to be effective October 1, 1992, 17 TexReg 6364.

End of Document