DECISION AND ORDER
This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.
A contested case hearing was held on May 5, 2008, to decide the following disputed issues:
In Docket No. 1:
- Whether the health care provider is entitled to additional reimbursement in the amount of $847.66 for services rendered to Claimant from January 29, 2007, through March 21, 2007?
In Docket No. 2:
In Docket No. 3:
Claimant appeared and was represented by JE, lay representative. Carrier appeared and was represented by TW, attorney.
The disputed issues herein arise from a health care provider's request for reimbursement of fees for physical therapy. When the Carrier's agent preauthorized the treatment, it imposed a limitation on the length of each of the sessions. The parties herein litigated the liability for the charges for sessions exceeding the length imposed in the preauthorization. The dates of service overlap among the sequences, but no individual date of service was addressed more than once in the three Medical Fee Dispute Resolution Findings and Decisions.
In Docket No. 2, Petitioner, (the HCP), requested reimbursement for services in the amount of $268.34, which included fees of $116.58 for a detailed history and a detailed examination under CPT Code 99214 and $15.00 for a work status report under CPT Code 99080-03. In the above MFDR No. for Docket No. 1, the Carrier was ordered to pay the HCP the total of $131.58 ($116.58 + $15.00 = $15) plus interest which fees were not appealed. The remaining $136.76 is the subject of the HCP's appeal and is for additional reimbursement for services rendered by the HCP on January 22, 2007. In the above MFDR No. for Docket No. 1, the Medical Fee Dispute Resolution Findings and Decision erroneously lists (Employer) as the self-insured Carrier; however the HCP and Carrier stipulated that (Self-Insured) is the correct carrier.
In each of the above docket numbers, the HCP submitted a request for physical therapy services to Carrier's preauthorization company which the HCP asserts was in accordance with Rule 134.600(f) in that the request included "specific health care, number of specific treatments, and the specific period of time requested to complete the treatment". The services were preauthorized by Carrier's preauthorization company with this qualification, "Per CMS [Centers for Medicare & Medicaid Services] Guidelines, no more than 60 minutes should be utilized per physical therapy session." The HCP points out that there was no agreement between the HCP and the Carrier to modify the request. Rule 134.600(n) provides:
"The carrier shall not condition an approval or change any elements of the request as listed in subsection (f) of this section, unless the condition or change is mutually agreed to by the health care provider and carrier and is documented."
No request for reconsideration of the preauthorization was made by the HCP, and the HCP rendered the physical therapy services. Carrier then paid the HCP for the sessions as if they were all 60 minutes each, and the amounts in dispute in the above issues represents the charges for the physical therapy sessions in excess of 60 minutes each that fell within the periods listed in the issues. Carrier denied reimbursement for those excess portions of the treatment citing reason code,
"152F-Payment adjusted because the payer deems the information submitted does not support this many services. *Documentation does not support the medical necessity for treatment exceeding 60 mins. Reference Trailblazer Physical Medicine Guidelines,"
and ANSI [American National Standards Institute] reason code,
"62-Payment denied/reduced for absence of, or exceeded, pre-certification/authorization."
The HCP asserts that there is no "four-unit standard" [60 minute standard] in the industry by arguing that CMS Guideline states,
"For all PM&R [Physical Medicine and Rehabilitation Modalities] modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline. Treatment times per session may vary based upon the patient's medical presentation. Treatment time, typically, should be a minimum of 45-60 minutes to provide full, optimal care to the Medicare beneficiary. Additional time may be required for the more complex and slow-to-respond patients. In these cases, documentation of these exceptional services must be maintained in the patient's medical record and available upon request."
The HCP also argues that Carrier's denial of reimbursement constitutes an improper retrospective review of preauthorized services and relies upon Texas Labor Code Sec. 413.014 (e) which states,
"If a specified health care treatment or service is preauthorized as provided in this section, that treatment or service is not subject to retrospective review of the medical necessity of the treatment or service."
Carrier's brief correctly notes,
"Despite the Provider's contention, the Self-Insured did not retrospectively deny the services in question. The 'denial' actually occurred prior to any services being performed and thus, by definition, could not have been denied retrospectively. It was during the preauthorization process that limitations were put in place which stated the provider could not perform more than the allowed 4 units of therapy per session. This limitation was put in place to avoid any retrospective denial."
Texas Labor Code Section 408.021 provides that 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. Health care reasonably required is further defined in Texas Labor Code Section 401.011 (22a) as health care that is clinically appropriate and considered effective for the injured employee's injury and provided in accordance with best practices consistent with evidence based medicine or, if evidence based medicine is not available, then generally accepted standards of medical practice recognized in the medical community. Health care under the Texas Workers' Compensation system must be consistent with evidence based medicine if that evidence is available. Evidence based medicine is further defined in Texas Labor Code Section 401.011 (18a) to be the use of the current best qualified scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines.
In accordance with the above statutory guidance, the Division of Workers' Compensation has adopted treatment guidelines by Division Rule 137.100. This rule directs health care providers to provide treatment in accordance with the current edition of the Official Disability Guidelines (ODG), and such treatment is presumed to be health care reasonably required as defined in the Texas Labor Code. Thus, the focus of any health care dispute starts with the health care set out in the Official Disability Guidelines (ODG).
The Preface to the ODG states,
"Generally there should be no more than 4 modalities/procedural units in total per visit, allowing the PT visit to focus on those treatments where there is evidence of functional improvement, and limiting the total length of each PT visit to 45-60 minutes unless additional circumstances exist requiring extended length of treatment. Treatment times per session may vary based upon the patient's medical presentation but typically may be 45-60 minutes in order to provide full, optimal care to the patient. Additional time may be required for the more complex and slow to respond patients. While an average of 3 or 4 modalities/ procedural units per visit reflect the typical number of units, this is not intended to limit or cap the number of units that are medically necessary for a particular patient, but documentation should support an average greater than 4 units per visit. These additional units should be reviewed for medical necessity, and authorized if determined to be medically appropriate for the individual injured worker."
In the preauthorizations herein, these are the "Reviewer Comments":
"Preauthorization is based on medical necessity per DWC Rule 413.014 [actually Texas Labor Code Sec. 413.014]. . . . Per CMS Guidelines, no more than 60 minutes should be utilized per physical therapy session. Over the course of physical therapy treatment, CMS Guidelines that 75% of the modalities should be active. Treatment utilizing Physical and Occupational therapy to the same body part on the same date of service is considered a duplication of services. This medical necessity decision is based on the internal and national guidelines, review of evidence-based literature, medical training and experience of physician reviewer, narrative description of services and not on any CPT codes the provider may have included in the request.
Without anything more specific from the HCP, Carrier properly limited the time to 60 minutes. The HCP failed to seek a greater number of units based on medical necessity and failed to request a reconsideration of the preauthorization if it considered the limiting language to be improper or unauthorized. The HCP proceeded to render services utilizing more units than authorized which it has done in treating other Claimants. This pattern of attempting to utilize more units with other injured workers is documented in Carrier's written brief and exhibits.
The HCP is required to be specific in what it is requesting; and Carrier is required to be specific in what it is denying. If the limit of the session length was an improper preauthorization, then the limiting preauthorization could be construed as a total denial of preauthorization. As a denial of preauthorization, the HCP would not be entitled to any reimbursement for any portion of the eighteen sessions. Finally, the HCP has the burden of proof herein to reverse the Medical Fee Dispute Resolution Findings and Decision. The HCP did not meet its burden of proof. Therefore, since the HCP delivered treatment under the limitations stated by the Carrier, the HCP is entitled only to reimbursement for 60 minutes or four-unit sessions. The HCP is not entitled to the additional reimbursement for the physical therapy services rendered on the subject dates.
Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.
FINDINGS OF FACT
- The parties stipulated to the following facts:
A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
B.On _____________Claimant was the employee of (self-insured), when he sustained a compensable injury.
CONCLUSIONS OF LAW
- The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
- Venue is proper in the (City) Field Office.
- In Docket No. 1, the health care provider is not entitled to additional reimbursement of $847.66 for services rendered to Claimant from January 29, 2007, through March 21, 2007, in that the requested reimbursement was for services which were not preauthorized.
- In Docket No. 2, the health care provider is not entitled to additional reimbursement of $136.76 for services rendered to Claimant on January 22, 2007, in that the requested reimbursement was for services which were not preauthorized.
- In Docket No. 3, the health care provider is not entitled to additional reimbursement of $360.19 for services rendered to Claimant from January 12, 2007, through January 31, 2007, in that the requested reimbursement was for services which were not preauthorized.
In Docket No. 1, the health care provider is not entitled to additional reimbursement of $847.66 for services rendered to Claimant from January 29, 2007, through March 21, 2007, in that the requested reimbursement was for services which were not preauthorized. In Docket No. 2, the health care provider is not entitled to additional reimbursement of $136.76 for services rendered to Claimant on January 22, 2007, in that the requested reimbursement was for services which were not preauthorized. In Docket No. 3, the health care provider is not entitled to additional reimbursement of $360.19 for services rendered to Claimant from January 12, 2007, through January 31, 2007, in that the requested reimbursement was for services which were not preauthorized.
Self-Insured Carrier is not liable for the additional reimbursements sought herein by HCP. Claimant remains entitled to medical benefits for the compensable injury in accordance with Texas Labor Code Sec. 408.021.
The true corporate name of the insurance carrier is (SELF-INSURED) and the name and address of its registered agent for service of process is
(CITY), TEXAS (ZIP CODE)
Signed this 4th day of August, 2008.
Charles T. Cole