HomeMy WebLinkAboutIR 26-0088 - 2026-08-04 - Informal Report
1 of 2 1.3.12 WORKERS' COMPENSATION PEER REVIEW GUIDELINES - KRISTEN SMITH, HUMAN RESOURCES DIRECTOR
INFORMAL REPORT TO CITY COUNCIL MEMBERS
SUBJECT: WORKERS' COMPENSATION PEER REVIEW GUIDELINES - KRISTEN SMITH,
HUMAN RESOURCES DIRECTOR
DATE: 08/04/26 NUMBER: IR 26-0088
TO THE MAYOR AND MEMBERS OF THE CITY COUNCIL
The purpose of this Informal Report is to provide a follow-up to the June 23, 2026, City Council
Work Session requesting an overview of the medical peer review process.
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 and scope of
employment.
To determine whether a claim is compensable, third-party administrators may request a
medical peer review, in accordance with state law. These reviews may be requested for a
variety of reasons, including, but not limited to, evaluating the extent of an injury, determining
causation, and medical necessity. Regardless of the reason for the request, state law mandates
specific requirements that govern the peer review process.
The peer review process is a collaborative assessment between an injured/ill worker’s
treating provider and an independent medical provider (reviewer).
All relevant and updated medical records are mandated to be provided to the reviewer.
The reviewer does not treat or examine the patient but follows state mandated protocol
for determining medical necessity.
State law also mandates the report content and can impose sanctions on reviewers who
do not adhere to required guidelines.
Guidelines
State law governs the peer review process and credential requirements of the peer review
physician. In addition, the regulations outline the required components of medical peer review
reports and the conditions under which insurance carriers may request additional reviews. A
valid peer review must clearly document the medical evidence used, summarize relevant
clinical history, list all materials reviewed, and provide an explanation supporting the reviewer’s
recommendation.
2 of 2 Insurance carriers are prohibited from seeking repeated peer reviews for the same dates of
service unless specific criteria are met, such as the need for a different specialty, new medical
evidence, incomplete initial review, or purposes unrelated to determining medical necessity.
When a peer review report is used to deny or reduce benefits or determine compensability, the
carrier must provide copies to the treating doctor, involved health‑care providers, the injured
employee, and the employee’s representative to ensure transparency and due process.
Summary
In closing, the peer review process is a collaborative assessment between the injured or ill
employee’s treating provider and an independent medical reviewer. This collaboration ensures
that decisions related to pre-authorization, medical necessity, and benefit determinations are
grounded in both the treating provider’s firsthand clinical understanding and an external
specialist’s objective, evidence‑based evaluation. It reinforces transparency, fairness, and
consistency in how care decisions are made, in accordance with the law.
For questions regarding this information, please contact Kristen Smith, Human Resources
Director at 817-392-2697.
Jesus “Jay” Chapa
City Manager
ISSUED BY THE CITY MANAGER FORT WORTH, TEXAS