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At a Glance:
Title:
09025-m4r
Date:
September 12, 2008

09025-m4r

September 12, 2008

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.

ISSUE

A contested case hearing was held on September 4, 2008, to decide the following disputed issue:

  1. Whether Dr. V is entitled to reimbursement of $978.63 for services rendered to Claimant from October 30, 2006, through November 1, 2006?

PARTIES PRESENT

Petitioner/Subclaimant Dr. V, D.C., appeared pro se. Carrier appeared and was represented by PW, attorney.

BACKGROUND INFORMATION

Dr. V has provided chiropractic services to Claimant on an ongoing basis for several years. The reimbursement in dispute is for services performed on October 20, October 31, and November 1, 2007. The fees were denied by Carrier because Dr. V failed to properly document that the services were performed; and the Medical Fee Dispute Resolution Findings and Decision {MFDR NO.) entered on May 14, 2008, upheld the denial.

Dr. V argues that the Carrier has previously and has subsequently paid for the same types of services without more documentation than was provided for the subject dates herein. Dr. V relies upon the treatment plan submitted in the preauthorization process and his billings using CMS-1500's with appropriate coding for the services. However, there is no documentation that the services were actually performed.

In finding that Dr. V is not entitled to the reimbursement of $978.63, the decision cited above states,

"A review of the medical record submitted for the above disputed DOS does not support the billing of the therapy modalities. The hour long treatment of the therapeutic procedures (97110) is not documented. The manipulation (9894) is not documented. The 15 minute manual therapy code (97140) nor the 156 minute neuromuscular reeducation treatment code (97112) is [not] documented as being performed. The electrical stimulation (G0283) and the mechanical traction (97012) are not documented as being performed. The 'cardiovascular['], 'stretching['], and 'synergy['] slots on the report do not support the modalities as billed above. Per Rule 134.202(b), payment is not recommended."

Because Dr. V failed to document that the services were actually performed subsequent to the performance of the services, he is not entitled to reimbursement. There is general mention of Claimant's response to treatment in the SOAP notes, but no documentation that identifies actual performance of the services requested in the preauthorization process. The CMS-1500's are insufficient to document the actual performance of the services.

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

  1. 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 (Employer), when he sustained a compensable injury.

  • Carrier delivered to Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • Services rendered to Claimant from October 30, 2006, through November 1, 2006, by Dr. V were not supported by proper documentation.
  • CONCLUSIONS OF LAW

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
    2. Venue is proper in the (City) Field Office.
    3. Dr. V is not entitled to reimbursement of $978.63 for services rendered to Claimant from October 30, 2006, through November 1, 2006.

    DECISION

    Dr. V is not entitled to reimbursement of $978.63 for services rendered to Claimant from October 30, 2006, through November 1, 2006.

    ORDER

    Carrier is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

    The true corporate name of the insurance carrier is DALLAS NATIONAL INSURANCE COMPANY and the name and address of its registered agent for service of process is

    MR. BILL HAGAN

    DALLAS NATIONAL INSURANCE COMAPNY

    14160 DALLAS PARKWAY, SUTIE 500

    DALLAS, TEXAS 75254

    Signed this 12th day of September, 2008.

    Charles T. Cole
    Hearing Officer

    End of Document
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