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At a Glance:
Title:
15011-m4r
Date:
November 19, 2014

15011-m4r

November 19, 2014

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and the Rules of the Texas Department of Insurance, Division of Workers’ Compensation. For the reasons discussed herein, the Hearing Officer determines that Respondent/Self-Insured is not liable to Petitioner/Provider in the amount of $1,345.00 for services rendered to Claimant.

STATEMENT OF THE CASE

On November 7, 2014, K. Eugene Kraft, a Division hearing officer, held a contested case hearing to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the findings of Medical Fee Dispute Resolution that the health care provider is not entitled to $1,345.00 for services rendered to Claimant between May 18, 2005, and June 23, 2010?

PARTIES PRESENT

Petitioner/Provider appeared by and through MJL, lay representative. Respondent/Self-Insured appeared and was represented by MD, attorney. Claimant did not appear and his attendance was excused.

EVIDENCE PRESENTED

The following witnesses testified:

For Petitioner: ML

PH

For Respondent: None

The following exhibits were admitted into evidence:

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

Petitioner’s Exhibits: None

Respondent’s Exhibits: CR-A through CR-C

DISCUSSION

Claimant sustained a compensable injury on (Date of Injury). Petitioner’s witnesses testified that it provided Claimant reasonable and necessary treatment for the compensable injury in the form of the following services on the dates listed, and that Petitioner submitted bills to Respondent in the amounts listed:

Table 1

May 18, 2005

CPT Code 92557

$95.00

May 18, 2005

January 26, 2006

CPT Code 95267

$35.00

May 18, 2005

CPT Code 95591

$95.00

August 9, 2005

May 3, 2006

July 27, 2006

July 12, 2007

March 16, 2009

April 14, 2009

August 7, 2009

August 26, 2009

December 16, 2009

January 26, 2009

March 17, 2010

June 23, 2010

CPT Code 99201

$45.00/date

August 12, 2009

HCPCS Code V5090

$500.00

August 17, 2009

CPT Code 92593

$45.00

Under M4-11-0829-01, the fee request was denied because a) billing was not submitted timely to the Respondent; b) the request for Medical Fee Dispute Resolution was not timely filed with the Division’s MDR Section as provided by 28 Texas Administrative Code §133.307(c)(1); c) copies of all medical bills were not included with the request for Medical Fee Dispute Resolution as provided by 28 Texas Administrative Code §133.307(c)(2)(A); d) the request for Medical Fee Dispute Resolution did not include complete form DWC-60 tables as provided by 28 Texas Administrative Code §133.307(c)(2)(B); e) the request for Medical Fee Dispute Resolution did not include copies of all applicable medical records as provided by 28 Texas Administrative Code §133.307(c)(2)(E).

No evidence that the Division’s Medical Fee Dispute Resolution Section erred in its Findings and Decision or that such findings were contrary to the preponderance of the evidence was offered at the hearing.

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:
    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 the (Employer), Employer, when he sustained a compensable injury.
    3. On (Date of Injury), Employer provided workers’ compensation insurance as a Self-Insurer.
  2. Respondent delivered to Petitioner a single document stating the true corporate name of Respondent, and the name and street address of Respondent’s registered agent for service, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  3. Petitioner did not submit proper billing to Respondent for the dates of service and in the amounts listed above until after the 95th day after the date on which the health care services were provided to Claimant.
  4. Petitioner did not timely or properly request Medical Dispute Resolution as required pursuant to 28 Texas Administrative Code §133.307.

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 not contrary to the findings of Medical Fee Dispute Resolution that the health care provider is not entitled to the sum of $1,345.00 for services rendered to Claimant on the dates listed herinabove.

DECISION

Respondent/Self-Insured is not liable to Petitioner/Provider in the amount of $1,345.00 for services rendered to Claimant.

ORDER

Respondent/Self-Insured 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 self-insurer is (SELF-INSURED) and the name and address of its registered agent for service of process is

LEROY GOODSON

221 EAST 9TH STREET, SUITE 206

AUSTIN, TEXAS 78701-2510

Signed this 19th day of November, 2014.

K. Eugene Kraft
Hearing Officer

End of Document
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