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Title: 

453-03-3621-m4

Date: 

February 20, 2004

Type: 

Medical Fees

453-03-3621-m4

DECISION AND ORDER

Continental Casualty Company (Continental) appealed a Texas Workers’ Compensation Commission (Commission) Medical Review Division (MRD) order denying its request for a refund of a claim it paid to North Texas Pain Recovery Center, f/k/a Lake Arlington Center for Pain Management (North Texas). In effect, MRD concluded that Continental waived its right to medical resolution because it did not request a refund from North Texas within the 45-day deadline stated in the Commission’s rules (the waiver issue). In Order No. 5, the Administrative Law Judge (ALJ) concluded that Continental’s failure to request a refund within the 45 days did not waive its right to medical dispute resolution.[1] This decision concludes that Continental’s refund request should be granted because it paid the provider twice for the same services.

I. PROCEDURAL HISTORY

A hearing was convened on October 29, 2003, before the undersigned Administrative Law Judge (ALJ) at the State Office of Administrative Hearings (SOAH), Austin, Texas. The parties submitted evidence on the waiver issue as well as Continental’s substantive appeal of its reimbursement request. MRD was represented by Timothy P. Riley, attorney. Continental was represented by David L. Swanson, attorney. North Texas was represented by its attorney, Peter N. Rogers. The hearing was recessed to permit the parties to file briefs on the waiver issue. The parties filed briefs, and Texas Mutual Insurance Company filed an amicus curiae brief. In Order No. 4,

issued on January 14, 2004, the ALJ requested additional briefing. The parties responded and the hearing record closed on January 26, 2004.

II. DISCUSSION

A. Background

The parties stipulated to the following facts:

  1. On August 14, 2000, Continental received a bill for dates of service July 31, August 1, August 2, August 3, and August 4, 2000.
  2. North Texas charged $1,400 for each date of service for total charge of $7,000.
  3. On or before September 22, 2000, North Texas received a TWCC-62, which approved payment of $1,120 for each date of service except there was no payment for August 1, 2000.
  4. On or before September 25, 2000, North Texas received a $4,480 payment from Continental.
  5. On or before September 29, 2000, North Texas sent Continental another copy of the bill for the same services.
  6. On or before October 13, 2000, Continental sent North Texas a TWCC-62 which approved payment of $1,120 for each of the five dates of service.
  7. On or before October 16, 2000, North Texas received a $5,600 payment for the dates of service.
  8. On July 13, 2001, Continental requested a refund for an overpayment of $4,480.
  9. The following is undisputed:
  10. North Texas denied Continental’s request for overpayment.[2]
  11. Continental requested medical dispute resolution.
  12. The MRD ruled against Continental because it did not request a refund from North Texas within 45 days of receiving a completed medical bill.
  13. Continental requested a hearing not later than the twentieth day after receiving notice of the MRD decision.
  14. B Analysis

This decision concludes that North Texas should be ordered to repay Continental $4,480 based on undisputed evidence that Continental paid twice for the same services. There was no argument that Continental did not overpay. Although North Texas gave its reasons for not refunding the overpayment, as described in footnote 2 above, it is undisputed that its reasons for withholding

the money are not at issue in this hearing.

III. FINDINGS OF FACT

  1. On August 14, 2000, Continental Casualty Company (Continental) received a bill for dates of service July 31, August 1, August 2, August 3, and August 4, 2000.
  2. North Texas charged $1,400 for each date of service for total charge of $7,000.
  3. On or before September 22, 2000, North Texas received a TWCC-62, which approved payment of $1,120 for each date of service except August 1, 2000, for which there was no payment.
  4. On or before September 25, 2000, North Texas received a $4,480 payment from Continental.
  5. On or before September 29, 2000, North Texas sent Continental another copy of the bill for the same July 31-August 4, 2000, services.
  6. On or before October 13, 2000, Continental sent North Texas a TWCC-62, which approved payment of $1,120 for each of the five dates of service.
  7. On or before October 16, 2000, Continental North Texas received a $5,600 payment for the dates of service.
  8. On July 13, 2001, Continental requested a refund for an overpayment of $4,480.
  9. Continental’s July 13, 2001, letter clearly and sufficiently explained its reasons for requesting a refund, but did not include an explanation of benefits.
  10. North Texas denied Continental’s request for overpayment.
  11. Continental requested medical dispute resolution.
  12. The Texas Workers’ Compensation Commission Medical Review Division ruled against Continental because it did not request a refund from North Texas within 45 days of receiving a complete medical bill.
  13. Continental requested a hearing not later than the twentieth day after receiving notice of the MRD decision.
  14. All parties received not less than 10 days’ notice of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  15. All parties had an opportunity to respond and present evidence and argument on each issue involved in the case.

V. CONCLUSIONS OF LAW

  1. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code Ann. §413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
  2. All parties received adequate and timely notice of the hearing. Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  3. The Labor Code does not provide that Continental waived its right to refund by not requesting a refund from North Texas within 45 days of receiving a complete medical bill.
  4. The Commission’s rules do not provide that Continental waived its right to medical dispute resolution by not requesting a refund from North Texas within 45 days of receiving a complete medical bill.
  5. Continental did not waive its right to medical dispute resolution by not including an explanation of benefits with its July 13, 2001, letter explaining its reasons for requesting a refund. Tex. Labor Code Ann. §408.027; 28 Tex. Admin. Code § 133.304.
  6. North Texas should pay Continental $4,480, plus interest. 28 Tex. Admin. Code § 133.304(r).

ORDER

IT IS THEREFORE ORDERED that North Texas Pain Recovery Center, f/k/a Lake Arlington Center for Pain Management pay Continental Casualty Company $4,480 plus interest.

Signed February 20, 2004.

JAMES W. NORMAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Order No. 5 is incorporated into this order for all purposes.↑
  2. North Texas explained that it offset the $4,480 in dispute against what it considered to be an underpayment of $8,800 resulting from Continental’s paying $140 per hourly session for the 273 hours of service over the entire course of treatment rather than the $175 charged by North Texas. North Texas requested medical dispute resolution to challenge Continental’s $140 per session payment, but the MRD issued an order denying its claim. Ex. 6. North Texas did not appeal that ruling and it is not an issue in this case.↑