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At a Glance:
Title:
09031
Date:
October 10, 2008
Status:
Medical Fees

09031

October 10, 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 10, 2008 with the record closing on September 26, 2008 to decide the following disputed issue:

Whether the health care provider (Provider) is entitled to additional reimbursement in the amount of $1,102.50 for services rendered to Claimant from May 31, 2007 through June 28, 2007?

PARTIES PRESENT

Provider/Petitioner appeared and was represented by LD, lay representative. Carrier/Respondent appeared and was represented by DS, attorney.

BACKGROUND INFORMATION

Petitioner, KD, D.C., requested reimbursement for services in the amount of $1,102.50 billed under CPT code 97110 for 4 units ($126.00 each) performed on eight occasions between May 31, 2007 and June 28, 2007 and for 3 units ($94.50) performed on June 14, 2007. On May 9, 2008, the Medical Fee Dispute Resolution Officer determined that, based on the documentation submitted by the parties and in accordance with the provisions of Texas Labor Code Section 413.031, the Requestor (Provider) is entitled to reimbursement in the amount of $1,102.50 plus applicable accrued interest per Division rule 134.130. The Carrier appealed the Division's order indicating that the Carrier authorized nine sessions rather than 12 and that the Carrier reimbursed the Provider for 60 minutes of therapy per session not the 120 minutes per therapy session that the Provider seeks the additional reimbursement.

The Provider submitted a request for pre-authorization of additional services for four weeks at three days per week (12 sessions) of therapeutic exercises (1-8 units depending on injury and necessity); attended electrical stimulation (1 unit); and manual therapy (1-3 units depending on injury and necessity). The Carrier authorized nine (9) sessions rather than the 12 as requested by the Provider and the Provider requested reconsideration. The Provider provided therapy on nine dates of service between May 31, 2007 and June 28, 2007. The Provider billed two hours for therapeutic exercises and 30 minutes for each office visit on each date of service. The Carrier reimbursed the Provider for each office visit and for 60 minutes of therapy for each date of service. The $1,102.50 represents the charges for the physical therapy sessions in excess of 60 minutes each for the period from May 31, 2007, through June 28, 2007. Carrier denied reimbursement for those excess portions of the treatment.

The Provider 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 noted that the Provider was paid for the therapy it had pre-authorized up to the limit allowed by the Division's official treatment guideline. Carrier stated that it did not pay for units that exceeded the limit allowed by the treatment guidelines because the Provider did not document the need for unusually lengthy sessions. The Carrier pre-authorized the services for the range of units requested. The Carrier retrospectively limited the length of the requested services pursuant to the 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."

DISCUSSION

The Provider submitted a request for pre-authorization of additional services for four weeks at three days per week (12 sessions) of therapeutic exercises (1-8 units depending on injury and necessity); attended electrical stimulation (1 unit); and manual therapy (1-3 units depending on injury and necessity). The Carrier approved nine (9) sessions and did not limit nor reduce the number of units for any of the modalities including CPT code 97110 or CPT code 97140-59. The Claimant's therapy sessions exceeded the 60 minutes as suggested in the ODG. The Carrier reimbursed the Provider for only 60 minute sessions. The Provider is required to be specific in what she is requesting and Carrier is required to be specific in what it is denying. The Carrier has the burden of proof herein to reverse the Medical Fee Dispute Resolution Findings and Decision rendered under MFDR Tracking No. M4-08-3652-01. The Carrier did not meet its burden of proof. Therefore, since the Carrier did not limit the number of units in its pre-authorization of the proposed services, the treatment or service is not subject to retrospective review of the medical necessity of the treatment or service and the Provider is entitled to the additional reimbursement of $1,102.50.

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 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.
  • Carrier improperly denied reimbursement of $1,102.50 for services rendered to Claimant from May 31, 2007 and June 28, 2007 in that the requested reimbursement was for services which were preauthorized.
  • 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. The health care provider is entitled to additional reimbursement in the amount of $1,102.50 for services rendered to Claimant from May 31, 2007 and June 28, 2007.

    DECISION

    The Provider is entitled to additional reimbursement in the amount of $1,102.50 for services rendered to Claimant from May 31, 2007 and June 28, 2007.

    ORDER

    Carrier is liable to pay additional reimbursement of $1,102.50 plus applicable accrued interest to Provider for services rendered to Claimant from May 31, 2007 through June 28, 2007.

    The true corporate name of the insurance carrier is AMCOMP ASSURANCE COMPANY and the name and address of its registered agent for service of process is

    CORPORATION SERVICE COMPANY

    800 BRAZOS, SUITE 350

    AUSTIN, TX 78701

    Signed this 10th day of October, 2008.

    Carol A. Fougerat
    Hearing Officer

    End of Document
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