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At a Glance:
Title:
11108
Date:
February 23, 2011
Status:
Medical Fees

11108

February 23, 2011

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.

ISSUES

A contested case hearing was held on January 25, 2011 with the record closing on February 23, 2011 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Respondent/Provider, is entitled to reimbursement in the amount of $396.24 for dates of service September 15, 2009 to September 17, 2009?

PARTIES PRESENT

Petitioner/Carrier appeared and was represented by RL, attorney. Respondent/Provider failed to appear. Claimant did not appear and her appearance was excused.

BACKGROUND INFORMATION

Although properly notified, Provider did not appear for the medical fee contested case pre-hearing scheduled for 10:00 a.m. on January 25, 2011. Prior to the pre-hearing held in this matter, the Claimant’s attendance was excused. Provider was sent a 10-day letter to allow it the opportunity to respond and offer evidence. The Provider did not respond to the 10-day letter. The record was opened on January 25, 2011 and the Petitioner/Carrier (Carrier) was afforded the opportunity to present evidence regarding its appeal of the Medical Fee Dispute Resolution (MFDR) order dated December 15, 2010.

On August 26, 2009, Provider requested preauthorization for physical therapy under CPT code 97110 and CPT code 97140. Provider requested three 15 minute treatments of CPT code 97110 and one 15 minute session of CPT code 97140 for each session. The Carrier preauthorized the requested physical therapy up to 12 treatments. On September 15, 2009, Provider performed one hour of physical therapy under CPT code 97110 which exceeded the preauthorized amount by one treatment. On September 16, 2009, Provider performed another hour of physical therapy under CPT code 97110 and an additional 15 minutes of physical therapy under CPT code 97140. Provider billed Carrier for 12 treatments under CPT code 97110, one treatment under CPT code 99212 and one treatment under CPT code 97140. Carrier tendered payment to Provider for nine of the twelve treatments under CPT code 97110 and both treatments under CPT codes 99212 and 97140. Provider requested reconsideration seeking reimbursement for the additional three treatments of physical therapy under CPT code 97110.

The Division’s MFDR officer determined that Provider was entitled to additional reimbursement for the nine treatments of physical therapy under CPT code 97110 and one treatment each under CPT codes 99212 and 97140 for a total reimbursement amount of $396.24. The Provider had requested reimbursement for an additional treatment which was not paid by the Carrier. The Provider did not request preauthorization for the additional three treatments of physical therapy under CPT code 97110 and the Carrier did not approve preauthorization for those three treatments. The MFDR officer approved the correct amount for the services that were preauthorized; however, the Carrier has already reimbursed the Provider for that amount. The MFDR order is for “additional reimbursement” which the Provider is not entitled to receive. Therefore, the preponderance of the evidence is contrary to the MFDR officer’s decision dated December 15, 2010 and the Provider is not entitled to any additional reimbursement for those 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. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
  2. On _____________, Claimant was the employee of (Employer).
  3. Claimant sustained a compensable injury on _____________.
  4. The Division sent a single document stating the true corporate name of the Carrier, and the name and street address of the Carrier's registered agent with the 10-day letter to Provider at its address of record. That document was admitted into evidence as Hearing Officer’s Exhibit Number 2A.
  5. Although properly notified, Provider did not appear for the contested case pre-hearing scheduled for January 25, 2011 nor did the Provider respond to the 10-day letter.
  6. The Claimant’s attendance at the January 25, 2011 pre-hearing was excused.
  7. No evidence was received to show that Provider had good cause for failing to appear for the medical contested case pre-hearing scheduled for January 25, 2011.
  8. On December 15, 2010, the MFDR officer determined that the Provider is entitled to additional reimbursement in the amount of $396.24 for the dates of service of September 15, 2009 to September 17, 2009.
  9. The preponderance of the evidence presented by the Carrier is contrary to the decision of the Medical Fee Dispute Resolution Findings and Decision that Provider is entitled to additional reimbursement in the amount of $396.24 for dates of service of September 15, 2009 to September 17, 2009.

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 preponderance of the evidence is contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Provider, is entitled to reimbursement in the amount of $396.24 for dates of service of September 15, 2009 to September 17, 2009.

DECISION

(Healthcare Provider), Provider, is not entitled to additional reimbursement in the amount of $396.24 for dates of service of September 15, 2009 to September 17, 2009.

ORDER

Provider is not entitled for the reimbursement at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury _____________, in accordance with the Texas Labor Code §408.021.

The true corporate name of the insurance carrier is WC SOLUTIONS and the name and address of its registered agent for service of process is:

JERRY EDWARDS

1004 MARBLE HEIGHT DRIVE

MARBLE FALLS, TX 78654

Signed this 23rd day of February, 2011.

CAROL A. FOUGERAT
Hearing Officer

End of Document
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