Once an injury has occurred and the employer has been notified, the employer has a responsibility to report the claim to their insurance workers’ compensation insurance carrier. This claim is then forwarded and on file with the Division of Workers’ Compensation (DWC). The DWC is overseen by the Texas Department of Insurance (TDI).

Texas is one of the few states that allow employers to choose either to participate in obtaining or subscribing to State workers’ compensation insurance or administering their own. If an employer chooses to provide their own work comp insurance they must choose to adhere to the rules set forth by Texas work comp or provide their own written injury process rules to all stakeholders including the injured worker, doctor, insurance company and TDI upon request, these employers are termed non - subscribers. Non – subscribers are becoming more popular for employer cost containment and insurance flexibility and currently make up approximately 45% of the employers in Texas.

Most insurance companies, both subscriber and non- subscriber, have departments that handle different responsibilities. The adjuster is the gatekeeper and is in charge of initial establishment of the claim and determining whether to accept the claim or dispute it. The adjuster is also the person that pays financial benefits and determines medical benefits. The case manager is the person that handles issues of working with the employer and injured worker regarding time lost from work and attempts to negotiate light duty or expedite the work comp process in order to return the injured back to work.

Most treatment must be approved by a pre-authorization that is outlined in the Official Disability Guidelines (ODG). This process can either be performed by the same insurance company or commonly delegated to a contracted third party administrator. The pre-authorization process is based completely on medical necessity as it relates to the clinical documentation submitted. While the relatedness or extent of injury is determined by the adjuster and at times by “independent” medical doctors contracted by the insurance company. In other words there are two different criteria that must be met in order to be afforded treatment under Texas workers’ compensation: (1) medical necessity and (2) compensability.

It is certainly easy to understand why injured workers have a difficult time with the workers compensation process and why there tends to be confusion even among the treating doctors and insurance companies. We hope this has helped explain some of the basic processes and wish you the best in your recovery.