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At a Glance:
Title:
12117-m4r
Date:
June 22, 2012

12117-m4r

June 22, 2012

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 June 22, 2012 to decide the following disputed issue:

Whether the health care provider (Provider/Petitioner) is entitled to medical fee payment in the amount of $283.56 for services rendered to Claimant on April 18, 2011?

PARTIES PRESENT

Provider/Petitioner appeared and was represented by PC, lay representative. Carrier/Respondent appeared and was represented by BJ, attorney.

Claimant was not present and her attendance was excused.

EVIDENCE PRESENTED

The following witnesses testified:

For Provider: None

For Carrier: PC

RB

The following exhibits were admitted into evidence:

Hearing Officer’s Exhibits: HO-1 and HO-2

Provider’s Exhibits: A through C

Carrier’s Exhibits: 1 through 10

BACKGROUND INFORMATION

The health care provider (Provider) rendered services to Claimant on April 18, 2011. Provider submitted a bill for reimbursement in the amount of $283.56 to Texas Mutual Insurance Company (Carrier). Carrier denied payment due to untimely filing for reimbursement. Provider appealed the denial to Medical Fee Dispute Resolution (MFDR). The MFDR officer determined that the dispute was not filed pursuant to Division rules at 28 Texas Administrative Code §133.20(b) and concluded that the requestor failed to support its position that reimbursement is due. The specific findings of the MFDR officer are contained in Carrier’s exhibit 6.

Pursuant to Rule 133.20 (b), except as provided in Labor Code §408.0272(b), (c) or (d), a health care provider shall not submit a medical bill later than the 95th day after the date the services are provided. In accordance with subsection (c) of the statute, the health care provider shall submit the medical bill to the correct workers' compensation insurance carrier not later than the 95th day after the date the health care provider is notified of the health care provider's erroneous submission of the medical bill. A health care provider who submits a medical bill to the correct workers' compensation insurance carrier shall include a copy of the original medical bill submitted, a copy of the explanation of benefits (EOB) if available, and sufficient documentation to support why one or more of the exceptions for untimely submission of a medical bill under §408.0272 should be applied. The medical bill submitted by the health care provider to the correct workers' compensation insurance carrier is subject to the billing, review, and dispute processes established by Chapter 133, including §133.307(c)(2)(A) - (H) of this title (relating to MDR of Fee Disputes), which establishes the generally acceptable standards for documentation.

In response to the MFDR findings, Provider submitted a letter dated April 13, 2012 (Provider’s Exhibit A) indicating that the initial bill was submitted to Secure Horizons and that Secure Horizons received the electronic billing on April 26, 2011 and forwarded the claim to Health Texas Medical Group. After Health Texas Medical Group denied the claim, the bill was submitted the Carrier, Texas Mutual Insurance Company. Provider maintains that, due to the lack of information regarding the proper Carrier, it met the exception to the 95 day filing deadline and that the information provided demonstrates proof required by Texas Labor Code Ann. §408.0272.

Pursuant to Texas Labor Code Ann. §408.0272, (b) Notwithstanding Section 408.027, a health care provider who fails to timely submit a claim for payment to the insurance carrier under Section 408.027(a) does not forfeit the provider's right to reimbursement for that claim for payment solely for failure to submit a timely claim if: (1)the provider submits proof satisfactory to the commissioner that the provider, within the period prescribed by Section 408.027(a), erroneously filed for reimbursement with: (A)an insurer that issues a policy of group accident and health insurance under which the injured employee is a covered insured; (B)a health maintenance organization that issues an evidence of coverage under which the injured employee is a covered enrollee; or (C)a workers' compensation insurance carrier other than the insurance carrier liable for the payment of benefits under this title; or (2)the commissioner determines that the failure resulted from a catastrophic event that substantially interfered with the normal business operations of the provider. (c)Notwithstanding Subsection (b), a health care provider who erroneously submits a claim for payment to an entity described by Subdivision (1) of that subsection forfeits the provider's right to reimbursement for that claim if the provider fails to submit the claim to the correct workers' compensation insurance carrier within 95 days after the date the provider is notified of the provider's erroneous submission of the claim.

It is undisputed that Provider did not submit the bill for reimbursement to Carrier for the services provided to Claimant on April 18, 2011 until August 16, 2011 which was not within 95 days of the date of service. Provider maintains that it met the requirements for the exceptions under Texas Labor Code Ann. §408.0272 because it erroneously filed for reimbursement with Secure Horizons, a health insurance company providing benefits through the Medicare Advantage Plan. Provider stated that it had been reimbursed by Secure Horizons for prior bills submitted in 2009 for this Claimant. It should be noted that Provider had also been reimbursed for services provided to Claimant by Carrier in 2008. Provider failed to prove that Claimant was covered by a policy of group accident and health insurance as defined in Chapter 1251.001(2) of the Insurance Code. Additionally, Provider failed to include, in its request for reimbursement from Carrier, a copy of the original medical bill submitted and sufficient documentation to support why one or more of the exceptions for untimely submission of a medical bill under §408.0272 should be applied. Because Provider failed to timely and properly submit a complete and correct medical bill to the proper Carrier pursuant to Rule 133.20(b), Provider forfeited the right to reimbursement for this claim in the amount of $283.56.

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 present stipulated to the following facts:
    1. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
    2. On (Date of Injury), Claimant was the employee of (Employer), Employer, when she sustained a compensable injury.
    3. On April 5, 2012, MFDR determined that the requestor was entitled to $0.00 reimbursement for the disputed services.
  2. On (Date of Injury), Employer provided workers’ compensation coverage with Texas Mutual Insurance Company, Carrier.
  3. The 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.
  4. The health care provider failed to timely and properly submit a medical bill to the Carrier for the reimbursement of $283.56 in accordance to Rule 133.20(b).

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 not entitled to reimbursement in the amount of $283.56 for services rendered to Claimant on April 18, 2011.

DECISION

The health care provider is not entitled to reimbursement in the amount of $283.56 for services rendered to Claimant on April 18, 2011.

ORDER

Carrier is not liable to pay Provider for additional reimbursement of $283.56 for services rendered to Claimant on April 18, 2011.

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

RON O. WRIGHT

6210 EAST HIGHWAY 290

AUSTIN, TX 78723

Signed this 22nd day of June, 2012.

Carol A. Fougerat
Hearing Officer

End of Document
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