DECISION AND ORDER

I. SUMMARY

Cleburne Physical Therapy (Provider) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD), which denied its request for reimbursement of $1,078.52 from Reliance National Indemnity Company (Carrier) for services (Disputed Services) that it provided to R.M. (Claimant). The Carrier does not dispute that the Disputed Services were provided and reasonably medically necessary or that the reimbursement sought exceeds TWCC’s applicable medical fee guidelines. However, the Carrier questions whether the Provider ever sent bills requesting reimbursement from the Carrier for those services.

As set out below, the Administrative Law Judge (ALJ) finds that the Provider sent its bills to and requested reimbursement for the Disputed Services from the Carrier and the Carrier, in violation of the TWCC’s rules, neither reimbursed nor explained within 45 days of receiving those bills and request why it would not reimburse the Provider. Accordingly, the ALJ finds that the Carrier is obligated to reimburse the Provider $1,078.52 for the Disputed Services and orders Carrier to pay the Provider that amount.

II. BACKGROUND

The Claimant sustained a compensable injury (Injury), and the Provider furnished the disputed physical therapy services to him from December 26, 2000, through February 23, 2001. The Disputed Services included hot/cold pack, ultrasound, e-stim-unattended, therapeutic procedure, paraffin, work conditioning initial two hours, and work conditioning additional hours. The Disputed Services were reasonable and medically necessary to treat the Injury. For them, the Provider seeks a total reimbursement of $1,078.52, which lies within the TWCC’s Medical Fee Guidelines. Those facts are not in dispute.

III. DISCUSSION

The Provider questions whether, but does not specifically deny that, the Claimant sent or that it received bills requesting reimbursement for the Disputed Services. Within 45 days of receiving the bill for services, a carrier must pay or deny payment or request reimbursement for any overpayment by issuing an EOB. 28 Texas Administrative Code (TAC) §133.304 (a), (b), and (c). Based on those rules, the Provider argues that it had no obligation to send an EOB or pay a bill that it never received.

In part, if not whole, the dispute concerning the sending and receiving of bills stems from the fact that the Carrier is in receivership. The receiver is the Texas Property and Casualty Insurance Guaranty Association (Receiver), which appeared at the hearing, through counsel, on behalf of the Carrier. The Receiver argues that it has not been able to locate the Provider’s bills for the Disputed Services in the records it obtained from the Carrier. Moreover, both parties agree, with a minor exception, that the Carrier never sent an explanation of benefits (EOBs) to the Provider.^[1]

The Provider’s office manager, April Horton, testified that the Provider sent the bills to the Carrier shortly after the Disputed Services were provided, and contemporaneous copies of some of those bills are in evidence. Ex. 1, pp. 29, 67, 68, and 69; and Tape. Confusingly, the bills for the Disputed Services provided on February 19, 20, 21, and 23, 2001, that are in evidence are dated July 27, 2001. Ex. 1, pp. 31, and 32. Obviously, those documents did not even exist and could not have been sent to the Carrier as bills shortly after the time when services were performed in February 2001. Ms. Horton explained that the Provider keeps all of its billing information on its computer and does not keep hard copies. Thus, when Provider did not receive reimbursement and resent its bills to the Carrier requesting reimbursement in July 2001, the bills were reprinted from the Provider’s computer, and the computer software automatically dated the document on the print date: July 27, 2001. This evidence is sufficient to convincingly show that the Provider sent bills to the Carrier for all of the Disputed Services shortly after the dates that the Disputed Services were provided, or at the latest by shortly after July 27, 2001.

Based on that evidence, the ALJ concludes that the Carrier more likely than not received the bills by shortly after July 27, 2001. Since 28 TAC §133.304 (a), (b), and (c) required the Carrier to send an EOB to the Provider either paying the bills or explaining why not within 45 days of receipt of the bills, more than 45 days have passed, and even now the Carrier raises no substantive objection to the bills, the ALJ finds that Carrier is obligated to pay the Provider for the Disputed Services and orders the Carrier to so pay.

II. FINDINGS OF FACT

1. ___(Claimant) sustained a work-related injury (Injury) on_________, while his employer was _________ and its workers’ compensation insurance carrier was Reliance National Indemnity Company (Carrier).
2. Cleburne Physical Therapy (Provider) furnished physical therapy services (Disputed Services) to the Claimant from December 26, 2000, through February 23, 2001, that were reasonably medically necessary to treat the Injury.
3. The Disputed Services included hot/cold pack, ultrasound, e-stim-unattended, therapeutic procedure, paraffin, work conditioning for the initial two hours of certain visits, and additional hours of work conditioning during certain visits.
4. The reimbursement that the Provider now seeks for all of the Disputed Services totals $1,078.52.
5. The Provider sent bills to the Carrier for all the Disputed Services shortly after they were provided.
6. The Carrier received the Provider’s bills for the Disputed Services shortly after the Provider sent them to the Carrier.
7. The Carrier never paid those bills or sent an explanation of benefits (EOB) to the Provider.
8. On December 17, 2001, the Provider filed with the TWCC a request for medical dispute resolution concerning the Disputed Services.
9. MRD reviewed the dispute and denied the Provider’s request because it had not included related EOBs with the dispute resolution request.
10. The Provider appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
11. Notice of a July 22, 2002, SOAH hearing in this case was mailed to the Carrier and the Provider on June 24, 2002.
12. On July 22,. 2002, William G. Newchurch, an Administrative Law Judge (ALJ) with SOAH held a hearing on the Providers’s appeal at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
13. The Provider’s Office Manager, April Horton, appeared at the hearing representing the provider, and Steven Tipton appeared on behalf of the Carrier.

CONCLUSIONS OF LAW

1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. §§ 402.073(b) and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003. (West 2001).
2. Adequate and timely notice of the hearing was provided in accordance with Tex Gov’t. Code Ann. §§ 2001.051 and 2001.052 (West 2001).
3. As the party appealing the MRD’s decision, the Provider has the burden of proof in this matter pursuant to 28 Texas Administrative Code (TAC) §148.21(h) (2002).
4. Under Tex. Labor Code § 408.021(a) (West 2002), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
5. Based on the above Findings of Fact, the Disputed Services were reasonable medically necessary to treat the Injury.
6. The Commission’s Medical Fee Guidelines set out reasonable fees for the Disputed Services. 28 Tex. Admin. Code §134.201et seq.
7. Based on the above Findings of Fact, the reimbursement that the Provider now seeks for each of the Disputed Services, which totals $1,078.52, does not exceed any applicable TWCC Medical Fee Guideline.
8. Within 45 days of receiving a bill for services, a carrier must pay or deny payment or request reimbursement for any overpayment by issuing an EOB. 28 TAC §133.304(a), (b), and (c).
9. Based on the above Findings of Fact, the Carrier received bills for and requests for reimbursement of the Disputed Services from the Provider shortly after July 27, 2001, at the latest.
10. Based on the above Findings of Fact, more than 45 days have passed since the Carrier received bills from the Provider for the Disputed Services.
11. Based on the above Findings of Fact and Conclusions of Law, the Carrier is obligated to reimburse the Provider $1,078.52 for the Disputed Services.

ORDER

The Carrier shall reimburse the Provider $1,078.52 for the Disputed Services.

Signed August 12, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge

1. The minor exception included only a partial payment for three of the Disputed Services and as assertion that the bill exceeded the Medical Fee Guidelines. However, the Carrier never pressed that point at hearing and indicated, when the ALJ asked, that all of the requested reimbursements were reasonably priced.↑