DECISION AND ORDER

Hill Country Behavioral Health (Provider) requested a hearing to contest a medical fee dispute resolution order issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) regarding medical services provided to _____ (Claimant). In its order, the Division found that Provider was entitled to reimbursement in the amount of $2,400 from Transcontinental Insurance Company (Carrier). A contested case hearing was conducted in this case, and Provider appeared through its attorney, Allen T. Craddock, and Carrier appeared through its attorney, David L. Swanson. After considering the evidence and arguments presented, the Administrative Law Judge (ALJ) finds that Provider is entitled to total reimbursement of $18,850. Therefore, Carrier is ordered to reimburse that amount, and not the amount previously ordered by the Division.

Claimant suffered a compensable injury to her left wrist on ___, when her hand was caught in a conveyer belt at her place of employment. Thereafter, she received extensive treatment for her injury. On or about May 27, 2003, Provider sought preauthorization from Carrier to provide 30 days of chronic pain management to Claimant.^[1] In the request for preauthorization, Provider identified the treatment diagnosis with code 842.09: “sprains and strains of the wrist – other.” Thereafter, Carrier preauthorized 30 days of chronic pain management to occur between June 18, 2003, and September 30, 2003. The preauthorization came in the form of three letters, each separately authorizing 10 days of treatment between certain dates that generally did not overlap.^[2] A pre-program evaluation was conducted on Claimant on May 15, 2003, and the chronic pain treatments were provided between June 23, 2003, and September 18, 2003. After the treatments were rendered, Provider billed Carrier the total amount of $48,620 for the services.

Carrier denied reimbursement for all services provided, citing “extent of injury” as the basis for its denial. Essentially, Carrier contended that the treatment provided to Claimant was for a condition or diagnosis that was not part of her compensable injury. At the hearing, Carrier noted that Provider’s preauthorization request was for treatment for a wrist sprain or strain. But, in an order dated February 19, 2004, a hearings officer with the Texas Workers’ Compensation Commission (TWCC) found that Claimant’s work-related accident “caused left carpal tunnel syndrome and a left shoulder injury in the nature of a sprain/strain.” Thus, Carrier contends that Claimant’s compensable injury (which was noted by the TWCC hearings officer as carpal tunnel syndrome) was not the basis for the chronic pain management rendered by Provider (which was provided for a wrist sprain/strain). Therefore, Carrier argues it is not liable to reimburse any of the services.

Provider disagrees that the TWCC hearing officer’s decision limited Claimant’s injury to only carpal tunnel syndrome and a shoulder sprain/strain. Rather, Provider asserts that the TWCC hearing officer was instead addressing whether Claimant’s injury included a certain number of conditions—not whether it was limited to those conditions. In fact, in his decision, the TWCC hearing officer noted that he was addressing only two issues:

1. Does the compensable injury of _____, include the left shoulder, cervical spine, left carpal tunnel syndrome, and reflex sympathetic dystrophy?
2. Did the Claimant have disability from June 20, 2002, through October 30, 2003?^[3]

Based upon the language identifying the scope of issues before the TWCC hearing officer, Provider argues that the issues presented were not encompassing, but simply intended to determine whether Claimant’s compensable injury also included those conditions listed.

After considering the evidence, the ALJ agrees with Provider and concludes that the treatment provided to Claimant in this case was for her compensable injury. First, the ALJ notes that the issue before the TWCC hearing officer was simply whether Claimant’s compensable injury “included” the listed conditions. As such, the ALJ does not believe the TWCC hearing officer intended to fully and completely define the scope of Claimant’s compensable injury. Rather, he was only addressing those conditions specifically raised and presented to him. This conclusion appears to be supported by other determinations of the TWCC hearing officer.

For example, the TWCC hearing officer discussed Claimant’s treatment, noting that Claimant first received medical treatment when her employer sent her to Dr. Begia on May 21, 2002, who diagnosed Claimant with left arm pain.^[4] The hearing officer then notes that “by June 3, 2002, the diagnosis became left arm and wrist strain.”^[5] The hearing officer states that later, on June 12, 2002, Claimant began treatment with a Dr. Khan. Accordingly, from the TWCC hearing officer’s decision, it appears that Dr. Begia diagnosed Claimant with left wrist strain before she was ever seen by Dr. Khan. Later in his decision, the TWCC hearing officer stated “I find the initial reports of Dr. Begia as well as the test results of Dr. Pecha and Dr. Dutra to be the more credible and persuasive evidence. . . .”^[6] This is significant because, if Dr. Begia diagnosed Claimant with a “left arm and wrist strain,” it would be inconsistent for the TWCC hearing officer to find Dr. Begia’s reports persuasive but then conclude that Claimant’s injury did not include Dr. Begia’s diagnosis. Thus, the ALJ concludes that the TWCC hearing officer’s decision was not intended to exclude a left wrist sprain/strain from Claimant’s compensable injury.

Moreover, given the clear evidence (reflected even in the TWCC hearing officer’s decision) that various treating doctors had diagnosed Claimant with a wrist strain/sprain, it would be odd for the hearing officer to not identify those diagnoses as issues to be decided if the hearing officer were truly attempting to address all possible diagnoses that might be included in the extent of Claimant’s injury. The complete absence of the “wrist sprain/strain” diagnosis as a contested issue in the hearing officer’s decision indicates that the hearing officer was, in fact, not attempting to decide and resolve all diagnoses within Claimant’s extent of injury, but only those specifically raised in that particular dispute. Accordingly, the ALJ does not see the TWCC hearing officer’s decision as excluding a wrist strain/sprain from Claimant’s compensable injury.

Under the circumstances presented, therefore, the ALJ concludes that the chronic pain management in issue—which was based upon a diagnosis of wrist sprain/strain—was provided for Claimant’s compensable injury to her left wrist. Thus, Claimant’s denial of reimbursement based upon “extent of injury” is not justified.

Having determined that Carrier’s basis for denial was not justified, the ALJ still must determine the services for which Provider has shown itself entitled to reimbursement, and the proper amount of reimbursement allowed under the law. Because Provider was the party first requesting a hearing in this docket, it has the burden of proving its entitlement to reimbursement. Provider presented documentation of the various procedures in issue and reflecting what services were provided. However, as noted even by Provider at the hearing, there are problems with the documentation that indicate numerous services billed by Provider may not have been provided or were not provided in the amounts identified in Provider’s billing. While it is not the ALJ’s role to analyze other possible grounds for denial of reimbursement that have not been raised properly by the Carrier,^[7] the ALJ also cannot order reimbursement for those services the record indicates were not actually provided to Claimant.

Although Provider billed for eight hours of chronic pain management nearly every date of service, the Claimant was often with Provider for less than eight hours. Moreover, Provider billed time for lunch, but there is no indication treatment was provided during lunch. The ALJ is obligated to ensure that the reimbursement amount matches the services actually rendered. The following chart reflects the ALJ’s conclusions on the actual amount of services provided, as reflected by the record evidence:

Date of ServiceActual Hours for Treatment

5/15/03 5

6/23/03 6

6/24/03 7

6/25/03 7

6/26/03 7

6/27/03 6.5

6/30/03 7

7/1/03 7

7/2/03 6.5

7/3/03 7

7/7/03 6.5

7/8/03 7

7/24/03 6.5

7/28/03 6.5

7/29/03 6.5

7/30/03 6.5

7/31/03 6.5

8/1/03 6.5

8/4/03 5

8/29/03 6.5

9/3/03 6.5

9/4/03 6.5

9/5/03 6.5

9/8/03 6.5

9/9/03 6.5

9/10/03 6.5

9/11/03 6.5

9/12/03 6.5

9/18/03 6.5

TOTAL: 188.5 In making the findings above, the ALJ rounded treatment times to the nearest one-half hour (rounding downward for times that were exactly halfway between the nearest half hours) and excluded one hour for lunch (when “lunch” was noted in the treatment records). Therefore, the ALJ concludes that 188.5 hours of treatment were actually provided.

Having determined that 188.5 hours of treatment were actually provided, the ALJ now must address the reimbursement rate. Provider billed $200 per hour for the chronic pain management program. Not long after the program was provided, though, TWCC adopted medical fee guidelines that limited reimbursement for such programs to $100 per hour for non-CARF-accredited facilities, and $125 per hour for CARF-accredited facilities. Although those guidelines do not directly apply, the ALJ finds that they are indicative of the fair and reasonable reimbursement rates for the services provided. And, the ALJ has a statutory mandate to ensure that reimbursement is fair and reasonable. The ALJ finds that, in the absence of evidence to the contrary, TWCC’s later-adopted medical fee guideline provides sufficient evidence of the fair and reasonable reimbursement rate for the services rendered. Because Provider was not CARF-accredited at the time, the ALJ concludes that it should be reimbursed at the rate of $100 per hour for the services rendered. Applying this rate to the 188.5 hours of treatment, the ALJ determines that the total appropriate reimbursement in this case is $18,850.

In conclusion, then, the ALJ finds that Provider is entitled to reimbursement of $18,850 for the chronic pain management services provided to Claimant. In support of this decision, the ALJ makes the following findings of fact and conclusions of law.

I. FINDINGS OF FACT

1. _____ (Claimant) suffered a compensable injury to her left wrist on ______, when her hand was caught in a conveyer belt at her place of employment.
2. On the date of injury, Transcontinental Insurance Company (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
3. Claimant received extensive treatment for her compensable injury.
4. On or about May 27, 2003, Hill Country Behavioral Health (Provider) sought preauthorization from Carrier to provide 30 days of chronic pain management to Claimant.
5. In the request for preauthorization, Provider identified the treatment diagnosis with code 842.09: “sprains and strains of the wrist – other.”
6. Carrier preauthorized 30 days of chronic pain management to occur between June 18, 2003, and September 30, 2003.
7. A pre-program evaluation was conducted on Claimant on May 15, 2003, and the chronic pain management program services were provided between June 23, 2003, and September 18, 2003.
8. After the treatments were rendered, Provider billed Carrier the total amount of $48,620 for the services related to the chronic pain management program.
9. Carrier denied reimbursement for all services, citing “extent of injury” as the basis for its denial.
10. After Carrier denied reimbursement for the services, Provider requested medical fee dispute resolution through the Texas Department of Insurance, Division of Workers’ Compensation (Division).
11. On December 12, 2008, the Division issued its findings and decision, holding that Carrier was obligated to reimburse Provider the sum of $2,400 for the disputed services.
12. On December 22, 2008, Provider requested a hearing by the State Office of Administrative Hearings (SOAH) to challenge the Division’s order.
13. The Division referred the matter to SOAH on December 31, 2008.
14. All parties received adequate notice of not less than 10 days 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. On March 23, 2009, SOAH Administrative Law Judge Craig R. Bennett held a contested case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. At the hearing, Provider appeared through its attorney, Allen T. Craddock, and Carrier appeared through its attorney, David L. Swanson. No other persons appeared or participated in the hearing, and the record closed that day.
16. The chronic pain management program at issue in this case was provided for Claimant’s compensable injury.
17. The fair and reasonable reimbursement rate for the services provided in this case is $100 per hour.
18. Provider rendered 188.5 hours of treatment to Claimant.

II. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order. Tex. Lab. Code §§ 402.073(b), 413.031, 413.0311, and 413.055; and Tex. Gov’t. Code ch. 2003.
2. 1. Notice of the hearing was proper and timely. Tex. Gov’t. Code §§ 2001.051-.052.
3. 1. Provider had the burden of proving by the preponderance of the evidence that it was entitled to reimbursement for the disputed services. 1 Tex. Admin. Code § 155.427; 28 Tex. Admin. Code § 148.14(a).
4. 1. Based on the above findings of fact and conclusions of law, Carrier is liable to Provider for $18,850, and is required to pay that amount to Provider, because the procedures in issue were properly preauthorized, were provided for Claimant’s compensable injury, and have not been previously reimbursed by Carrier.

ORDER

THEREFORE, IT IS ORDERED THAT Transcontinental Insurance Company is required to pay the sum of $18,850 to Hill Country Behavioral Health in reimbursement for the chronic pain management program services rendered in this case.

Signed April 9, 2009.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Ex. P-1, at 25.↑
2. Ex. P-1, at 22-24.↑
3. Ex. P-1, at 1.↑
4. Ex. P-1, at 3-4.↑
5. Ex. P-1, at 4.↑
6. Ex. P-1, at 4.↑
7. For example, the ALJ declines to consider Carrier’s arguments regarding the general inadequacy of the Provider’s documentation to show the extent of services rendered and the objective findings and notes regarding such services, because these were not properly raised as a ground for denial in the explanation of benefits.↑