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At a Glance:
Title:
09026
Date:
September 24, 2008
Status:
Medical Fees

09026

September 24, 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 July 24, 2008 to decide the following disputed issue:

Is Dr. BA (Provider) entitled to $500.00 plus interest under CPT Code 99456-WP for an MMI/IR evaluation performed on January 18, 2006?

PARTIES PRESENT

Carrier (Petitioner) appeared and was represented by JRT, attorney. Respondent (Provider) appeared and was represented by MV and LA, lay representatives.The employer representative was LM. Claimant did not appear, and her attendance was waived.

BACKGROUND EVIDENCE

On January 18, 2006, Dr. BA (Provider) performed a designated doctor evaluation to determine MMI/IR for Claimant, (Claimant). The Provider submitted a bill for $500.00 for this evaluation under CPT code 99456-WP. On May 5, 2008, the Medical Fee Dispute Resolution Officer approved fees in the amount of $500.00 for the evaluation performed on January 18, 2006 billed under CPT code 99456-WP. After an audit by the Carrier, the Carrier appealed the order issued by MDR contesting the $500.00 bill. It is undisputed that an EES-14 was approved and sent by the Division of Workers' Compensation on December 30, 2005 assigning Dr. BA as a designated doctor to determine MMI/IR. On that EES-14, Texas Mutual Insurance Company is identified as the insurance carrier and notice was sent to Dr. BA, the Claimant and Texas Mutual Insurance Company. It is also undisputed that Dr. BA performed the examination on January 18, 2006 and properly billed for this examination. The Carrier disputes liability for this examination on the basis that they were not notified of the evaluation, that the Claimant had already been certified to have reached MMI and assigned an IR by Dr. G in September 2004 and that Dr. G's certification had become final. Finality of Dr. G’s certification was adjudicated by the Division on May 25, 2006. The Carrier argued that, had they received notice of the appointment of Dr. BA as a designated doctor, they would have disputed that evaluation since it was not reasonable and necessary to determine MMI/IR.

It is apparent that the EES-14 appointing Dr. BA as a designated doctor incorrectly identified the insurance Carrier and was not sent to the proper carrier. However, the Carrier argued that, had they received the appointment of Dr. BA as an alternate designated doctor, they would have disputed such. In fact, the Carrier did dispute the appointment of Dr. BA in a PLN-11 dated January 3, 2006, prior to Dr. BA’s examination on January 18, 2006. The January 3, 2006 PLN-11 notes that the Carrier had not received the notification of the appointment (EES-14) of Dr. BA and that the first certification had become final under Rule 130.5. The Carrier obviously had knowledge of the appointment of Dr. BA as a designated doctor prior to Dr. BA’s examination and disputed this appointment even though the EES-14 was sent to the incorrect carrier. The preponderance of the evidence is not contrary to the findings of Medical Review and the Petitioner (Carrier) is liable for $500.00 plus applicable accrued interest for the MMI/IR evaluation performed on January 18, 2006 billed under CPT Code 99456-WP.

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 the State of Texas when she sustained a compensable injury.

C.On May 5, 2008, the Medical Fee Dispute Resolution Officer approved fees in the amount of $500.00 for the evaluation performed on January 18, 2006 billed under CPT code 99456-WP.

  • Carrier delivered to Claimant and Health Care Provider 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.
  • The preponderance of the evidence is not contrary to the decision of Medical Review rendered on May 5, 2008 that Respondent (Provider) is entitled to reimbursement for $500.00 under CPT Code 999456-WP for services rendered on January 18, 2006 and the Petitioner (Carrier) is liable for the $500.00 plus applicable accrued interest.
  • 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. BA (Provider) is entitled to $500.00 plus interest under CPT Code 99456-WP for an MMI/IR evaluation performed on January 18, 2006.

    DECISION

    Dr. BA (Provider) is entitled to $500.00 plus interest under CPT Code 99456-WP for an MMI/IR evaluation performed on January 18, 2006.

    ORDER

    Carrier (Petitioner) is ordered to pay benefits in accordance with this decision, the Texas

    Workers’ Compensation Act and the Commissioner’s Rules.

    The true corporate name of the insurance carrier is STATE OFFICE OF RISK MANAGEMENT (a self-insured governmental entity) and the name and address of its registered agent for service of process is

    For service in person, the address is:

    JONATHAN BOW, EXECUTIVE DIRECTOR

    STATE OFFICE OF RISK MANAGEMENT

    300 W. 15th STREET

    WILLIAM P. CLEMENTS, JR.

    STATE OFFICE BUILDING, 6TH FLOOR

    AUSTIN, TEXAS 78701

    For service by mail, the address is:

    JONATHAN BOW, EXECUTIVE DIRECTOR

    STATE OFFICE OF RISK MANAGEMENT

    P.O. BOX 13777

    AUSTIN, TEXAS 78711-3777

    Signed this 24th day of September, 2008.

    Carol A. Fougerat
    Hearing Officer

    End of Document
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