HomeMy WebLinkAboutIR 26-0079 - 2026-06-23 - Informal Report
1 of 2 1.3.4 WORKERS’ COMPENSATION SURGICAL APPEALS STATISTICS - KRISTEN SMITH, HUMAN RESOURCES DIRECTOR
INFORMAL REPORT TO CITY COUNCIL MEMBERS
SUBJECT: WORKERS’ COMPENSATION SURGICAL APPEALS STATISTICS - KRISTEN SMITH,
HUMAN RESOURCES DIRECTOR
DATE: 06/23/26 NUMBER: IR 26-0079
TO THE MAYOR AND MEMBERS OF THE CITY COUNCIL
The purpose of this Informal Report is to provide a follow-up to the March 7, 2026, Public
Safety Committee presentation, Workers’ Compensation Overview. Specifically, analysis on
the rate of Workers’ Compensation surgical requests that are initially denied but later
overturned through guidelines governed by the State of Texas.
Background
As a public entity, the city is required to provide Workers’ Compensation insurance coverage
for employees and is subject to the Texas Workers’ Compensation Act. This coverage is
provided to address injuries and illnesses that arise during the course of employment, while
performing a compensable task.
Surgical requests are evaluated based on Official Disability Guidelines (ODG) and generally
follow a review process as noted below. Throughout the review process, prior medical history
as well as new supporting documentation may be provided for consideration.
Initial Review
Evaluation of medical necessity based on ODG.
Peer-to-Peer Review
Collaborative review between the requesting provider and designated peer, based on
medical specialty.
Independent Review Organization
Neutral third-party review, designated by the Texas Department of Insurance.
Analysis
The following data is provided for FY2021-FY2026 (as of April 2026).
Surgical Requests Received- 846
Surgical Requests Denied- 190
Surgical Requests Appealed- 45
2 of 2 21 (46%) were upheld; and
24 (53%) were overturned
The following represent the primary reasons noted for overturned appeals.
13 were overturned through the medical review process (initial and/or peer-to-peer)
11 were overturned, following submission of additional medical documentation
Summary
As mentioned, the city is subject to Worker’s Compensation guidelines established by the
State of Texas. These provisions include the legal and medical framework for establishing
and receiving care, as well as additional provisions for appeal rights and presumptive
coverage for certain conditions.
The city adheres to these guidelines and partners with a third-party administrator (currently,
Sedgwick) to manage claims and support employees with navigating their available options.
For questions regarding this information, please contact Kristen Smith, Human Resources,
Civil Service and Civil Rights Director at Kristen.Smith@FortWorthTexas.gov or 817-392-2697.
Jesus “Jay” Chapa
City Manager
ISSUED BY THE CITY MANAGER FORT WORTH, TEXAS