DECISION AND ORDER

Russell Radican, D.C. (Provider), appealed the findings and decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission), which denied reimbursement for treatment rendered to a workers= compensation Claimant between March 19, 2003, and April 3, 2003. In this decision, the Administrative Law Judge (ALJ) finds Provider is not entitled to reimbursement from TPCIGA for Colonial Casualty Company (Carrier) for the disputed treatment.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Those issues are addressed in the findings of fact and conclusions of law without further discussion here.

The hearing in this matter convened and closed on February 9, 2005, at the State Office of Administrative Hearings (SOAH) before Steven M. Rivas, ALJ. Provider appeared and represented himself. Carrier appeared and was represented by Shelley Gatlin, attorney.

II.DISCUSSION

A. Background Facts

Claimant sustained a compensable injury on August 26, 1999, and sought treatment with Provider between March 19, 2003, and April 3, 2003. At some point following his compensable injury, Claimant moved from Texas to Memphis, Tennessee, where Provider practices. It is unclear what type of treatment Claimant underwent before he sought treatment with Provider. Additionally, Claimant’s treating doctor did not refer Claimant to Provider for the disputed treatment. Furthermore, the identity of Claimant’s treating doctor was not made part of the record.

Provider billed Carrier for the treatment, which was initially denied due to a billing error. Apparently, Provider failed to use a necessary billing modifier when he first billed Carrier. Provider again billed Carrier and was denied reimbursement due to Provider not being Claimant’s treating doctor. Provider appealed Carrier’s denial to the Commission’s MRD, which held that Provider was not entitled to reimbursement for the treatment rendered. Provider appealed the MRD ruling to SOAH.

B. Applicable Law

The Texas Labor Code contains the Texas Workers= Compensation Act (the AAct) and provides the relevant statutory requirements regarding compensable treatment for workers= compensation claims. In particular, Tex. Lab. Code Ann. ‘ 408.021(c) provides that except in an emergency, all health care must be approved or recommended by the employee’s treating doctor.

The Commission’s rule at 28 Tex. Admin. Code (TAC) ‘ 126.9(a) provides that any change in treating doctor requires approval from the Commission. Additionally, under 126.9(d), if an injured employee wants to change treating doctors, the employee shall submit to the field office handling the claim, reasons why the current treating doctor is unacceptable. Unless medical necessity exists for an immediate change, the submission shall be in writing on a form prescribed by the Commission. If the need for an immediate change exists, then the injured employee may notify the field office by telephone.

Pursuant to the Commission’s rule at 28 TAC ‘ 180.20(h)(1), all licensed doctors, whether on the approved doctors list or not, are entitled to reimbursement for providing necessary emergency or immediate post-injury medical care.

Emergency care is defined under 28 TAC ‘ 133.1(a)(7)(A) as the sudden onset a medical a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health and/or bodily functions in serious jeopardy, and/or serious dysfunction of any body organ or part.

C. Evidence and Analysis

Provider asserted he was entitled to reimbursement after he included the correct billing modifier to his treatment bills. Carrier argued that, as a matter of law, sending in the corrected modifier did not affect Provider’s status of not being Claimant’s treating doctor.

Provider testified tht Claimant first Aappeared on his doorstep on March 19, 2003, complaining of pain. Subsequently, Provider had several conversations with various Carrier representatives regarding Claimant’s workers= compensation claim. Provider argued he was informed on how to correct his billing but was not made aware that he would not be reimbursed if he was not listed as Claimant’s treating doctor. Had he been notified about not being Claimant’s treating doctor, Provider contended, he would have gone through the necessary steps to ensure reimbursement.

Carrier’s counsel argued that regardless of Provider’s circumstances, the law is clear on how health care providers are reimbursed for treatment rendered. There is no dispute that Provider was not Claimant’s treating doctor, and under the Act at ‘ 408.021(c), all health care must be approved by the employee’s treating doctor. The only exception would be in case of a medical emergency. However, the record does not reflect Claimant suffered from a medical emergency as defined under 28 TAC ‘ 133.1(a)(7)(A). The ALJ agrees with Carrier’s counsel that Claimant’s pain complaints were not severe enough to warrant a medical emergency.

Furthermore, Carrier argued, the Commission has rules in place under ‘ 126.9(d) for patients who wish to change treating doctors. In this case, because no medical emergency existed, Claimant was required to submit a request in writing to the Commission. However, Carrier asserted, even if a proper request was made, a change of residence alone (in this case from Texas to Tennessee) is not a sufficient reason to change treating doctors under ‘ 126.9(e).

Provider dmitted he does not routinely treat workers= compensation patients from Texas, and that he was not familiar with the rules regarding change of treating doctors. The ALJ also believes that Provider did Aeverything requested by the Carrier, and that he treated Claimant in good faith of being reimbursed. However, the ALJ is bound by the Commission rules regarding change of treating doctor. Therefore, because the disputed treatment was not recommended by the treating doctor, and Provider did not comply with the Commission’s rules regarding change of treating doctor, Carrier should not be ordered to reimburse Provider for the services rendered.

III.FINDINGS OF FACT

1. Claimant sustained a compensable injury on August 26, 1999.
2. Between March 19, 2003, and April 3, 2003, Russell Radican, D.C., (Provider) administered treatment to Claimant.
3. Provider is located in Memphis, Tennessee.
4. Provider billed TPCIGA for Colonial Casualty Company (Carrier) for the treatment rendered.
5. Carrier initially denied reimbursement due to Provider failing to include a proper billing modifier.
6. Provider included the correct modifier and resubmitted his bill for the disputed dates of service.
7. Carrier denied reimbursement due to Provider not being Claimant’s treating doctor.
8. Provider appealed this matter to the Commission’s Medical Review Division, which agreed with Carrier that reimbursement was not proper because Provider was not Claimant’s treating doctor.
9. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).
10. Notice of the hearing was sent August 5, 2004.
11. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
12. The hearing convened and closed on February 9, 2005, with Steven M. Rivas, Administrative Law Judge presiding. Provider appeared and represented himself. Carrier appeared and was represented by Shelley Gatlin, attorney.
13. The treatment rendered to Claimant was not recommended or prescribed by Claimant’s treating doctor.
14. Provider was not Claimant’s treating doctor when he rendered the treatment in question.
15. Claimant did not request a change of treating doctor before Provider rendered the treatment in question.

IV. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ‘ 413.031(d) and Tex. Gov=t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. ” 2001.051 and 2001.052.
4. Except in an emergency, all health care must be approved or recommended by the employee’s treating doctor in accordance with Tex. Lab. Code Ann. ‘ 408.021.
5. Provider was not Claimant’s treating doctor, nor did Claimant request a change of treating doctor as required by 28 Tex. Admin. Code Ann. (TAC) ‘ 126.9(a).
6. Pursuant to foregoing Findings of Facts and Conclusions of Law, Provider is not entitled to reimbursement for the treatment rendered to Claimant between March 19, 2003, and April 3, 2003.

ORDER

IT IS, THEREFORE, ORDERED that Carrier is not ordered to reimbursed Provider for the treatment rendered March 19, 2003, through April 3, 2003.

Signed April 11, 2005.

STEVEN M. RIVAS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS