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This summary sets forth various workers' compensation regulations regarding outpatient physical therapy services. The Workers' Compensation State Regulations resource may serve as a tool to assist in locating regulations. Please send database comments and corrections to advocacy@apta.org.
To the extent an individual or entity wishes to rely upon information contained in this resource, such reliance should be based upon an independent legal review and analysis of applicable law. This resource was prepared for informational purposes only and is not offered or intended, nor should it be relied upon, for legal advice for any specific set of circumstances. Additional legal doctrines, federal and state statutes, and case law not set forth herein may apply to your situation and such laws, rules and regulations can vary from state to state. You should consult with your own attorney to obtain specific legal advice on your particular facts and circumstances and applicable laws, rules and regulations.
Key Resources/Links
Agency:
Department of Insurance, Division of Workers' Compensation
Contact Information:
E-mail DWC Customer Services
News & Updates:
Texas Department of Insurance (TDI) News Releases
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Other:
Fee Guidelines and Information
Medical Fee Guideline Training Module
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | $55.30 | 1/1/13 to 12/31/13 Note: §134.203(b)(2) provides for adding a 10% incentive payment to the maximum allowable reimbursement for services in underserved areas |
www.tdi.texas.gov/wc/fee/documents/conversions.pdf www.tdi.texas.gov/wc/fee/documents/2mfginfo2008.pdf www.tdi.texas.gov/wc/rules/documents/134.pdf |
| What is the basis of the fee schedule for outpatient therapy services? | RBRVS | www.tdi.texas.gov/wc/fee/documents/2mfginfo2008.pdf | |
| Are there limits on the number of physical therapy visits allowed? | Yes | Per ODG and §134.600. Preauthorization, Concurrent Review, and Voluntary Certification of Health Care | www.tdi.texas.gov/wc/rules/documents/134.pdf |
| Are there limits on payment per visit for outpatient therapy services? | Yes | Subject to provider contracts with carriers, and Official Disability Guidelines | |
| Do regulations require use of treatment guidelines? | Yes | Official Disability guidelines, subchapter C §137.100. Treatment Guidelines | www.tdi.texas.gov/wc/rules/documents/137.pdf |
| Is a referral required in order to see a physical therapist? | Yes | Must be referred by treating physician per WCRI report; not found in rules | Workers' compensation medical cost containment: A national inventory, 2011 (WCRI report WC-11-35, April 2011) |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes - | §134.1. Medical Reimbursement (e) says if not in network, use department fee guidelines, negotiated contract, or fair and reasonable as defined in subsection (f) - can only be negotiated below the published rate in certified WC health care networks | www.tdi.texas.gov/wc/rules/documents/134.pdf |
| Can the injured worker be charged for any claim-related services? | No | Texas Labor Code 408.021 and 413.042 and Texas Administrative Code 126.9 | www.tdi.texas.gov/wc/employee/medicalben.html |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | Default to state practice act. | |
| Are there provider network and/or managed care regulations in place? | Yes | Tex Insurance Code Chapter 1305; 28 TAC Chapter 10 | www.statutes.legis.state.tx.us/Docs/IN/htm/IN.1305.htm http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=28&pt=1&ch=10 |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | No | ||
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | 28 TAC Chapter 134 §134.202 (e)(4) & §134.202 (g) | www.tdi.texas.gov/wc/rules/documents/134.pdf |
1 While some states use a mandatory fee schedule, many states have provisions for fees to be negotiated above or below the published fee schedule. "Yes + / - " indicates that fees can be negotiated above or below the fee schedule. "Yes -" indicates that fees can only be negotiated below the fee schedule.
The following payer types conduct business in this state.
Private Carriers - Yes
Self-insured Employers or Groups - Yes
Competitive State Fund - Yes
Exclusive State Fund - No
State Comp Fund (last resort) - No