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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

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 Carrier is liable for the additional $666.81 in reimbursement for the services rendered by Provider to Claimant for the compensable injury of (Date of Injury), on May 14, 2004; May 19, 2004; May 20, 2004; May 21, 2004; May 24, 20004, May 25, 2004; May 28, 2004; June 1, 2004; June 2, 2004; June 8, 2004; June 9, 2004; June 10, 2004; June 14, 2004; June 15, 2004; June 16, 2004; and July 5, 2004, as set forth in the Medical Fee Dispute Resolution Findings and Order dated February 28, 2014.

STATEMENT OF THE CASE

On February 28, 2014, a Medical Fee Dispute Resolution Findings and Decision was entered by the Division’s Medical Fee Dispute Resolution Officer that SCD Back & Joint Clinic, Respondent, is entitled to additional reimbursement in the amount of $666.81 plus interest for services rendered from May 14, 2004, through July 5, 2004, under HCPCS Code L4350, and CPT Codes 99212-25, 99211-25, 97012, 97024, 99213-25, 97012, 97024, and 99213-25. State Office of Risk Management, Petitioner, appealed the Medical Fee Dispute Resolution Findings and Decision by requesting a Medical Fee Contested Case Hearing in accordance with the Act and Rules.

A contested case hearing was held on May 27, 2014, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the Medical Fee Dispute Resolution Findings and Decision that SCD Back & Joint Clinic is entitled to additional reimbursement in the amount of $666.81 for the services involved in this dispute?

PARTIES PRESENT

Petitioner/Carrier, State Office of Risk Management, appeared and was represented by JT, attorney. Respondent/Provider, (Provider), appeared through DB, DC, a principal of the clinic.

EVIDENCE PRESENTED

No witnesses testified

The following exhibits were admitted into evidence:

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

Petitioner’s Exhibits P-A through P-F.

Respondent’s Exhibit R-1.

DISCUSSION

Carrier contends that Provider is not entitled to the reimbursement determined by the Medical Fee Dispute Resolution Officer in her order of February 28, 2014, because Provider failed to request reconsideration of its determination of the amount to be paid for the services provided within 10 months of the date of the service as required under Rule 133.250(b). It does not contend that the services were not reasonably necessary health care for the compensable injury of (Date of Injury), or that the amount of additional reimbursement calculated by the Medical Fee Dispute Resolution Officer is incorrect, only that Provider is barred from availing itself of the Division’s Medical Fee Dispute Resolution because it did not comply with the requirement that a request for reconsideration be tendered to Carrier before the matter could be submitted to the Division for dispute resolution. That condition precedent, Carrier asserts, defeats Provider’s entitlement to reimbursement in the amount calculated by the Medical Fee Dispute Resolution Officer.

In support of its assertion that Provider failed to request reconsideration of its bill in a timely manner, Carrier offered an affidavit from KK. Ms. K’ affidavit states that a thorough search of the claim file and computer records of AW was carried out under her direction and control, but the search revealed no record of a request for reconsideration dated October 18, 2004, from Provider prior to receiving a copy of the request from the Division on May 17, 2005.

Provider offered a copy of a request for reconsideration dated October 18, 2004, for the bills denied or reduced by Carrier that are the subject of this litigation. The request for reconsideration was signed by “A. B” of Provider’s Dispute Department and contains a certificate of service, again signed by “A. B” stating that a true and correct copy of the documentation attached to the request for reconsideration (and by implication the request for reconsideration itself) was mailed to Carrier at its correct Austin Post Office Box on October 18, 2004.

Rule 102.4: General Rules for Non-Commission Communications provides in part as follows:

(p) For purposes of determining the date of receipt for non-commission written communications, unless the great weight of evidence indicates otherwise, the Commission shall deem the received date to be five days after the date mailed via United States Postal Service regular mail; or the date faxed or electronically transmitted.

The preponderance of the evidence indicates that Provider placed its request for reconsideration into the mail on October 18, 2004. Carrier is deemed to have received that request for reconsideration on October 23, 2004. The only defense to liability in this matter, that it did not receive a request for reconsideration of the disputed bills within ten months of the date of service, is not supported by a preponderance of the evidence. The determination that Provider is entitled to $666.81 in additional reimbursement for serviced rendered for the compensable injury, as set forth in the Medical Fee Dispute Resolution Findings and Decision of February 28, 2014, is consistent with the preponderance of the evidence.

FINDINGS OF FACT

  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).
  3. On (Date of Injury), the State of Texas provided workers’ compensation insurance as a self-insurer through the State Office of Risk Management, the statutorily designated insurance carrier.
  4. On (Date of Injury), Claimant sustained a compensable injury.
  5. (Provider) provided reasonably necessary health care to Claimant for the compensable injury of (Date of Injury), on May 14, 2004, May 19, 2004, May 20, 2004, May 21, 2004, May 24, 20004, May 25, 2004, May 28, 2004, June 1, 20004, June 2, 2004, June 8, 20004, June 9, 2004; June 10, 2004, June 14, 2004, June 15, 2004, June 16, 2004; and July 5, 2004.
  6. Provider received partial payment from Carrier for the services set forth in Finding of Fact No. 5, and mailed a properly addressed request for reconsideration to Carrier via the United States Postal Service on October 18, 2004.
  7. Provider thereafter appealed Carrier’s failure to provide full payment for the services identified in Finding of Fact No. 5, to the Division and a medical fee dispute resolution officer determined that Provider is entitled to additional reimbursement in the amount of $666.81 for the services rendered as set forth in Finding of Fact No. 5.
  8. The preponderance of the evidence supports the dispute resolution officer’s determination that Provider is entitled to $666.81 as additional reimbursement for the services rendered by Provider to Claimant for the compensable injury of (Date of Injury), on May 14, 2004; May 19, 2004; May 20, 2004; May 21, 2004; May 24, 20004, May 25, 2004; May 28, 2004; June 1, 2004; June 2, 2004; June 8, 2004; June 9, 2004; June 10, 2004; June 14, 2004; June 15, 2004; June 16, 2004; and July 5, 2004.

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. (Provider) is entitled to additional reimbursement in the amount of $666.81 for reasonably necessary health care provided to Claimant for the compensable injury of (Date of Injury), on May 14, 2004; May 19, 2004; May 20, 2004; May 21, 2004; May 24, 20004, May 25, 2004; May 28, 2004; June 1, 2004; June 2, 2004; June 8, 2004; June 9, 2004; June 10, 2004; June 14, 2004; June 15, 2004; June 16, 2004; and July 5, 2004.

ORDER

Carrier is ordered to pay additional reimbursement to Provider in accordance with this decision, the Texas Workers’ Compensation Act, the Commissioner’s Rules and the Medical Fee Dispute Resolution Findings and Decision dated February 28, 2014, in this matter. Unpaid additional reimbursement, if any, shall be paid in a lump sum together with interest as provided by law.

The true corporate name of the insurance carrier is STATE OFFICE OF RISK MANAGEMENT and the name and address of its registered agent for service of process is

STATE OFFICE OF RISK MANAGEMENT

MAILING ADDRESS:

JONATHAN D. BOW

P.O. BOX 13777

AUSTIN, TEXAS 78711-3777

PHYSICAL ADDRESS:

JONATHAN D. BOW

300 W. 15TH STREET, 6TH FLOOR

AUSTIN, TEXAS 78701

Signed this 30th day of May, 2014.

KENNETH A. HUCHTON
Hearing Officer

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 opened on July 29, 2013, continued on September 16, 2013, and was concluded on November 19, 2013, with the record closing on that date, to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the decision of Medical Review that Respondent/Provider is entitled to additional reimbursement in the amount of $1,761.57 plus applicable accrued interest for dates of service of November 12-26, 2008?

PARTIES PRESENT

On July 29, 2013 Petitioner/Carrier appeared and was represented by PP, attorney. Respondent/Provider did not appear. Claimant did not appear.

On September 16, 2013 Petitioner/Carrier appeared and was represented by PP, attorney. Respondent/Provider did not appear. Claimant did not appear.

On November 19, 2013 Petitioner/Carrier appeared and was represented by PS, attorney. Respondent/Provider did not appear. Claimant did not appear.

EVIDENCE PRESENTED

The following witnesses testified:

For Claimant: None.

For Carrier: None.

For Provider: None.

The following exhibits were admitted into evidence:

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

Claimant’s Exhibits: None.

Carrier’s Exhibits: CR-A through CR-E.

Provider’s Exhibits: None.

BACKGROUND INFORMATION

The hearing opened on July 29, 2013. Carrier appeared and was represented by an attorney. Provider did not appear. Claimant did not appear. Ten day letters were sent to Provider and Claimant. Hearing Officer’s Exhibits HO-1 and HO-2 and Carrier’s Exhibits CR-A through CR-D were admitted into evidence. No evidence was offered by or in behalf of Provider or Claimant. Carrier’s motion for continuance was granted.

On September 16, 2013 the hearing resumed. Carrier appeared and was represented by an attorney. Provider did not appear. Claimant did not appear. There was no response to the Division’s 10 day letters.

There was no testimony. The evidence consisted of Hearing Officer’s Exhibits HO-1 (Medical Fee Dispute Resolution findings and decision and DWC-45A) and HO-2 (Carrier information form) and Carrier’s Exhibits CR-A (exhibit list), CR-B (managed care services agreement), CR-C (Medical Fee Dispute Resolution findings and decision), and CR-D (dispute documentation).

The case comes down to whether the fees in question were subject to a contractual agreement between Carrier and Provider. Carrier failed to offer sufficient documentation to the Medical Fee Dispute Resolution Officer (MF), and she ruled in favor of Provider.

Carrier argued there was a contractual relationship, as shown by its exhibits, however it developed that a lot of Carrier’s documentary evidence concerned a different medical fee dispute also involving a person named JP. Carrier’s motion for continuance was granted.

On November 19, 2013 the hearing resumed. Carrier appeared and was represented by an attorney. Provider did not appear. Claimant did not appear. There was no additional offer of evidence by Carrier. The alleged contractual agreement was never produced. Carrier failed to overcome the Medical Review decision by the preponderance of the evidence.

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 (Employer), Employer.
    3. On (Date of Injury) Employer provided workers’ compensation insurance with American Guarantee and Liability Insurance Company, Carrier.
    4. On (Date of Injury) Claimant sustained a compensable injury.
    5. Medical Review determined that Provider is entitled to additional reimbursement in the amount of $1,761.57 plus applicable accrued interest for date of service of November 12-26, 2008.
  2. The Division sent to Claimant and Provider at their addresses of record with the 10 day letters 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.
  3. Medical Review determined that Respondent/Provider is entitled to additional reimbursement in the amount of $1,761.57 plus applicable accrued interest for date of service of November 12-26, 2008.
  4. Carrier reduced payment for the disputed services “due to PPO contract”.
  5. There was no showing that the disputed services were subject to a contractual agreement between Carrier and Provider.
  6. Provider failed to appear for the July 29, 2013 contested case hearing and did not respond to the Division’s letter offering Provider the opportunity to have the hearing rescheduled.
  7. There was no showing of good cause for Provider’s failure to appear at the contested case hearing.
  8. Claimant failed to appear for the July 29, 2013 contested case hearing and did not respond to the Division’s letter offering Claimant the opportunity to have the hearing rescheduled.
  9. There was no showing of good cause for Claimant’s failure to appear at the contested case hearing.

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 decision of Medical Review that Respondent/Provider is entitled to additional reimbursement in the amount of $1,761.57 plus applicable accrued interest for dates of service of November 12-26, 2008.

DECISION

The preponderance of the evidence is not contrary to the decision of Medical Review that Respondent/Provider is entitled to additional reimbursement in the amount of $1,761.57 plus applicable accrued interest for dates of service of November 12-26, 2008.

ORDER

Carrier is liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with Section 408.021 of the Act.

The true corporate name of the insurance carrier is AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY, and the name and address of its registered agent for service of process is

CORPORATION SERVICE COMPANY

211 EAST 7th STREET, SUITE 620

AUSTIN, TEXAS 78701

Signed this 19th day of November, 2013.

Thomas Hight
Hearing Officer

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 medical contested case hearing was held on October 31, 2013 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider 2) is entitled to reimbursement in the amount of $612.00 for a functional capacity evaluation for date of service of July 15, 2009 for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Carrier appeared, and was represented by Attorney TR.

Respondent/Provider did not appear for the October 31, 2013 Medical Contested Case Hearing, and Claimant’s appearance was excused by the Hearing Officer.

BACKGROUND INFORMATION

Provider sought payment from Carrier for a functional capacity evaluation of Claimant that it administered during a patient visit on July 15, 2009, and on May 23, 2013, the Division’s Medical Fee Dispute Resolution Officer issued a decision holding that Provider was entitled to reimbursement in the amount of $612.00 from Carrier.

Carrier presented voluminous evidence to the effect that (Healthcare Provider 1), an entity established by Dr. HD, essentially required that a functional capacity evaluation be ordered for every designated doctor examination, regardless of whether the designated doctor was of the opinion that such a test was necessary or was aware that one had been ordered. (Healthcare Provider 1) also routinely billed for four hours, the maximum permissible time, for each functional capacity evaluation; the evidence, however, indicates that functional capacity evaluations usually lasted far less than the four hours billed for such service.

When it was discovered that (Healthcare Provider 1) was billing for services that were not provided, were not reasonable and necessary, or that took less time than claimed, Dr. D established a new entity, (Healthcare Provider 2), obtained a new address and tax identification number for that entity, and continued his previous billing practices. Dr. D has since been convicted of a criminal offense in conjunction with the above-described billing scheme.

Carrier’s evidence also indicates that the services billed did not conform to the American Medical Association’s CPT code 97750 for the services rendered, in that this CPT code mandates direct patient contact for the entirety of the time billed; the four-hour duration that Provider routinely billed for functional capacity evaluations does not comply with this requirement.

The preponderance of the evidence therefore is found to be contrary to the Medical Fee Dispute Resolution Findings and Decision that Provider is entitled to reimbursement in the total amount of $612.00 for the functional capacity evaluation for the date of service of July 15, 2009 for Claimant’s compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled is reduced from $612.00 to $00.00.

Even though all the evidence presented may not have been discussed in detail, it was considered; the Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

  1. On (Date of Injury), Claimant was employed by (Employer), Employer.
  2. On (Date of Injury), Employer subscribed to a policy of workers’ compensation insurance issued by the Texas Mutual Insurance Company, Carrier.
  3. On (Date of Injury), Claimant's residence was located within seventy-five miles of the (City) Field Office of the Texas Department of Insurance, Division of Workers' Compensation.
  4. Carrier mailed Provider and Claimant 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 Carrier’s Exhibit Number 1.
  5. On (Date of Injury), Claimant sustained damage or harm to the physical structure of his body while he was within the course and scope of his employment with Employer.
  6. The injury referenced in the previous Finding of Fact arose out of Claimant's employment with Employer.
  7. The Medical Fee Dispute Resolution Officer determined that Provider was entitled to reimbursement in the amount of $612.00 for the functional capacity evaluation with a date of service of July 15, 2009.
  8. The services for which Provider billed under CPT code 97750 were not shown to be necessary, and were billed at an excessive rate.
  9. Provider produced no evidence to show the duration of the functional capacity evaluation at issue in this case.

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 Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider 2) is entitled to reimbursement in the amount of $612.00 for a functional capacity evaluation with a date of service of July 15, 2009 for the compensable injury of (Date of Injury).

DECISION

(Healthcare Provider 2) is not entitled to reimbursement in the amount of $612.00 for a functional capacity evaluation with a date of service of July 15, 2009 for the compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled for that testing is reduced from $612.00 to $00.00

ORDER

Carrier is not liable for the reimbursement at issue in this hearing in the amount of $612.00. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

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

RICHARD J. GERGASKO

TEXAS MUTUAL INSURANCE COMPANY

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 1st day of November, 2013.

Ellen Vannah
Hearing Officer

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 October 17, 2013, to decide the following disputed issue:

  1. Is (Healthcare Provider) entitled to a fee of $612.00 for FCE testing on August 7, 2009?

PARTIES PRESENT

The petitioner/carrier (hereinafter “carrier”) appeared and was represented by TR, attorney. The respondent/provider (hereinafter “provider”) did not appear in person or by attorney, and also did not respond to a 10-day letter. The claimant's appearance was excused.

EVIDENCE PRESENTED

The following witnesses testified:

For the carrier:

  1. None

For the provider:

  1. None

The following exhibits were admitted into evidence:

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

The carrier’s Exhibits P-2 through P-19 and P-21 through P-25

None for the provider

BACKGROUND INFORMATION

A representative for the carrier appeared at the hearing, but the provider did not appear. A letter dated October 17, 2013 was mailed to the provider on October 17, 2013, to its last known address, giving the provider until October 27, 2013 to appear and show cause why it failed to appear for the benefit contested case hearing. Since October 27, 2013 fell on a Sunday, the provider had until October 28, 2013 to contact the Division. As of November 1, 2013 no response was received from the provider. The record was closed on November 1, 2013.

The bill the subject of this action that was submitted by the provider to the carrier was for four hours of FCE testing on the claimant on August 7, 2009.

HD, M.D., the owner of the provider has been indicted and convicted of fraudulent billing practices and ordered to pay restitution to the carrier. Part of the basis of that conviction was that the provider routinely billed the maximum permissible time for FCE’s, four hours, even though the evidence adduced indicated that the typical FCE would take a fraction of that time.

The carrier provided the affidavit of KH, a Senior Investigator with carrier, which highlighted the exaggerated and unnecessary nature of the provider’s billing practices and its failure to explain the actual duration of the FCE’s. The carrier’s evidence also indicated that the services billed by the provider did not conform to AMA CPT code 97750 for the service rendered, which specifically requires “direct one-on-one patient contact.” The evidence indicated that the four hours for which FCE’s were routinely billed by the provider failed to comply with that requirement.

The preponderance of the evidence is contrary to the MFDRFD that the provider is entitled to reimbursement in the total amount of $612.00 for the FCE for date of service August 7, 2009 for the claimant’s compensable injury of (Date of Injury). The amount of reimbursement to which the provider is entitled is reduced from $612.00 to $0.00.

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 Workers’ Compensation Division of the Texas Department of Insurance.
  2. The provider provided FCE testing to (Injured Worker), the claimant, on August 7, 2009.
  3. The FCE testing was provided to (Injured Worker), the claimant, by the provider in connection with the compensable injury sustained by the claimant.
  4. On August 7, 2009, (Injured Worker)’s employer provided workers’ compensation insurance with Texas Mutual Insurance Company, Carrier.
  5. The provider failed to appear for the Contested Case Hearing set on October 17, 2013 and did not respond to the Division’s letter offering it an opportunity to have the hearing rescheduled.
  6. No evidence was received that showed that the provider had good cause for its failure to appear for the Contested Case Hearing.
  7. The bill the subject of this action that was submitted by the provider to the carrier was for four hours of FCE testing on August 7, 2009.
  8. The provider did not provide four hours of FCE testing to the claimant on August 7, 2009.
  9. Since the provider did not appear, it is unknown how long the FCE testing actually lasted on August 7, 2009.
  10. The Division sent a single document stating the true corporate name of the carrier and name and street address of the carrier’s registered agent with the 10-day letter to the provider at the provider’s address of record. That document was admitted into evidence as Hearing Officer Exhibit Number 2.

CONCLUSIONS OF LAW

  1. The Workers’ Compensation Division of the Texas Department of Insurance has jurisdiction to hear this case.
  2. Venue is proper in the (City) Field Office.
  3. (Healthcare Provider) is not entitled to a fee of $612.00 for FCE testing on August 7, 2009.

DECISION

(Healthcare Provider) is not entitled to a fee of $612.00 for FCE testing on August 7, 2009.

ORDER

The relief requested by the carrier is granted.

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

RICHARD J. GERGASKO

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 1st day of November, 2013.

William M. Routon, II
Hearing Officer

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 October 9, 2013, with the record closed on October 21, 2013, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the Medical Fee Dispute Resolution Resolution Findings and Decision (MFDRD) that (Healthcare Provider 2) is entitled to reimbursement in the amount of $612.00 for a functional capacity evaluation (FCE) for date of service July 29, 2009, for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Carrier (hereinafter “Carrier”) appeared and was represented by TR, attorney.

Respondent did not appear for the October 9, 2013, medical contested case hearing (MCCH).

Claimant did not appear and his appearance was excused.

BACKGROUND INFORMATION

Although properly notified, Respondent failed to appear for the MCCH scheduled for 2:00 PM on Wednesday, October 9, 2013. A letter was mailed to Respondent on October 9, 2013, and the Respondent was advised in the letter that the MCCH had reconvened, and that the record would be held open for ten days to afford Respondent the opportunity to respond and request that the hearing be rescheduled to permit Respondent the right to present evidence on the disputed issue. Respondent failed to respond to the letter and the record was closed on Monday, October 21, 2013.

Concerning the disputed issue, the Division’s Medical Fee Dispute Resolution Officer issued a decision (“Medical Fee Dispute Resolution Findings and Decision” or MFDRD) holding that Respondent was entitled to reimbursement in the amount of $612.00 from Carrier.

According to the Health Insurance Claim Form 1500 with attached documentation, Respondent sought payment from Carrier for an FCE of Claimant that it administered during Claimant’s inpatient visit on July 29, 2009. (Healthcare Provider 1) was an entity established by HD, M.D. (Healthcare Provider 1) required an FCE to be ordered for every designated doctor examination whether the designated doctor was of the opinion that such a test was necessary or even aware that one had been ordered. In addition, (Healthcare Provider 1) would routinely bill the maximum permissible time for FCEs which was four hours even though the evidence adduced indicated that the typical FCE would take a fraction of that time.

When it was discovered that (Healthcare Provider 1) was billing fraudulently for services that were either not provided, were unnecessary, or simply took far less time than claimed, Dr. D established a new entity, (Healthcare Provider 2), with a new tax identification number to continue the practice in hopes of evading detection by the fraud investigators.

KH gave a sworn affidavit dated October 7, 2013. According to her affidavit, Ms. H is a Health Care Fraud Investigator for Carrier. Ms. H indicated that she conducted an investigation and determined that Respondent engaged in exaggerated and unnecessary billing practices and failed to explain the actual duration of the FCEs performed by Respondent. Dr. D has been convicted of fraudulent billing practices and has been ordered to pay restitution to Carrier.

According to the documentary evidence, the services billed by Respondent did not conform to the AMA CPT Code 97750 for the services rendered which specifically required “direct one-on-one contact.” In addition, the documentary evidence indicated that the four hours of FCEs were routinely billed by Respondent failed to comply with that requirement.

Based on the evidence presented in the hearing, the preponderance of the evidence is contrary to the MFDRD that Respondent is entitled to reimbursement in the amount of $612.00 for a FCE for date of service of July 29, 2009, for the compensable injury on (Date of Injury).

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 (Date of Injury), Claimant was the employee of (Employer), Employer.
  3. On (Date of Injury), Employer provided workers’ compensation insurance with Texas Mutual Insurance Company, Carrier.
  4. Claimant sustained a compensable injury on (Date of Injury).
  5. The Division sent a single document stating the true corporate name of the Carrier and the name and street address of Carrier’s registered agent for service with the letter to Respondent at its address of record. That document was admitted into evidence as Hearing Officer's Exhibit Number 2A.
  6. Respondent failed to appear for the October 9, 2013, medical contested case hearing and did not respond to the Division’s letter offering it an opportunity to have the hearing rescheduled.
  7. The services for which Respondent billed under AMA CPT Code 97750 for dates of service of July 29, 2009, were not shown to be necessary and were billed at an excessive rate.
  8. No evidence was produced by Respondent to show the actual duration of the FCE at issue.

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 Medical Fee Dispute Resolution Findings and Decision (MFDRD) that (Healthcare Provider 2) is entitled to reimbursement in the amount of $612.00 for a FCE for date of service on July 29, 2009, for the compensable injury of (Date of Injury). The amount of reimbursement to which Respondent is entitled for that testing is reduced from $612.00 to $0.00.

DECISION

(Healthcare Provider 2) is not entitled to reimbursement in the amount of $612.00 for an FCE for date of service on July 29, 2009, for the compensable injury of (Date of Injury). The amount of reimbursement to which Respondent is entitled for that testing is reduced from $612.00 to $0.00.

ORDER

Carrier is not liable for the benefits at issue in this hearing in the amount of $612.00. Claimant remains entitled to medical benefits for the compensable injury of (Date of Injury), in accordance with Texas Labor Code Ann. §408.021.

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

RICHARD J. GERGASKO, PRESIDENT

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723.

Signed this 28th day of October, 2013.

Wes Peyton
Hearing Officer

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 October 24, 2013, 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 $612.00 for Claimant’s compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Carrier appeared and was represented by TR, attorney.

Respondent/Provider did not appear and did not respond to a 10-day letter sent after the pre-hearing held on September 26, 2013. Claimant did not appear and his appearance was excused.

EVIDENCE PRESENTED

No witness testified.

The following exhibits were admitted into evidence:

Hearing Officer’s Exhibits HO-1 through HO-3

Claimant had no exhibits admitted.

Carrier’s Exhibits P-1 through P-5

Provider had no exhibits admitted.

BACKGROUND INFORMATION

Although properly notified, Provider failed to appear for the medical fee contested case pre-hearing scheduled for 2:00 p.m. on September 26, 2013. A letter advising the pre-hearing had convened and the record would be held open for ten days to afford Provider the opportunity to respond and request the pre-hearing be rescheduled to permit it to present evidence on the disputed issue was mailed to Provider on September 30, 2013. Provider failed to respond to the Division’s 10-day letter. The letter was returned as “Unavailable.” The medical contested case hearing was held as scheduled on October 24, 2013.

On May 23, 2013, the Division Medical Fee Dispute Resolution Officer issued a decision holding that Provider was entitled to reimbursement in the amount of $612.00 from Carrier for services rendered as a functional capacity evaluation performed on July 09, 2009. The services were allegedly performed during a Designated Doctor examination of Claimant for the compensable injury of (Date of Injury).

Carrier’s evidence indicates the services billed did not conform to AMA CPT code 97750 for the services rendered. The code specifically requires billing only for one-on-one direct face time. Provider’s reconsideration of the denied billing indicates it included medical preparation, determining claimant’s physical needs in order to outline a proper evaluation, creating a testing format for each individual claimant, and other administrative duties not related to direct one-on-one time. The reconsideration did not explain the services performed for this Claimant but just a general boilerplate form describing services it allegedly provides on each claimant, most of which are not one-on-one direct face time. The evidence indicates the four hours that were billed by the Provider were not actually provided as billed and failed to comply with the billing requirements for CPT code 97750. No evidence was provided indicating the amount of time that was actually spent testing.

The preponderance of the medical evidence is contrary to the Medical Fee Dispute Resolution decision that Provider is entitled to be reimbursed in the amount of $612.00 for the FCE allegedly performed on July 09, 2009. The amount of reimbursement to which the provider is entitled is reduced to $0.00.

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. Carrier 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 sustained a compensable injury.
    3. On (Date of Injury), Employer provided workers’ compensation insurance with Texas Mutual Insurance Company.
    4. The Medical Fee Dispute Resolution Officer determined (Healthcare Provider) should be reimbursed in the amount of $612.00.
  2. The Division sent a single document stating the true corporate name of the Carrier and the name and street address of Carrier’s registered agent for service with the 10-day letter to the Provider at Provider’s last known address of record. That document was admitted into evidence as Hearing Officer Exhibit Number 2.
  3. The services for which Provider billed under AMA CPT code 97750 were not shown to be necessary and were billed at an excessive rate.
  4. No evidence was produced by Provider to show the actual duration of the FCE.
  5. Provider did not have good cause for failing to appear at the contested case hearing.

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 $612.00 for Claimant’s compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled for that testing is reduced from $612.00 to $0.00.

DECISION

Provider is not entitled to reimbursement in the amount of $612.00 for Claimant’s compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled for that testing is reduced from $612.00 to $0.00.

ORDER

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

RICHARD GERGASKO, PRESIDENT

6210 HIGHWAY 290 EAST

AUSTIN, TEXAS 78723.

Signed this 24th day of October, 2013.

KEN WROBEL

Hearing Officer

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 medical contested case hearing (MCCH) was held on October 1, 2013 to decide the following disputed issue:

Is a preponderance of the evidence contrary to the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) that (Healthcare Provider 2) is entitled to additional reimbursement in the amount of $612.00 for a functional capacity evaluation (FCE) for date of service July 15, 2009 for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Carrier (hereinafter “Carrier”) appeared and was represented by TR, attorney.

Respondent/Provider (hereinafter “Provider”) did not appear for the October 1, 2013 MCCH.

Claimant did not appear and his appearance was excused.

BACKGROUND INFORMATION

On May 30, 2013, the Division’s MFDR Officer issued a decision (“Medical Fee Dispute Resolution Findings and Decision” or MFDRFD) holding that Provider was entitled to reimbursement in the amount of $612.00 from Carrier.

The Provider sought payment from Carrier for an FCE of Claimant that it administered during a patient visit on July 15, 2009. (Healthcare Provider 1), an entity established by Dr. D, essentially required an FCE to be ordered for every designated doctor examination, whether the designated doctor was of the opinion such a test was necessary or even aware that one had been ordered. (Healthcare Provider 1) also routinely billed the maximum permissible time for FCE’s, four hours, even though the evidence adduced indicates that the typical FCE would take a fraction of that time.

When it was discovered that (Healthcare Provider 1) was billing fraudulently for services that were either not provided, were unnecessary, or simply took far less time than claimed, Dr. D established a new entity, (Healthcare Provider 2), with a new tax identification number to continue the practice in the hopes of evading detection by fraud investigators.

Carrier put forth testimony in the hearing from Ms. H, a Senior Investigator with Carrier. Ms. H’s testimony highlighted the exaggerated and unnecessary nature of the Provider’s billing practices and its failure to explain the actual duration of the FCE’s. Dr. D has been convicted of fraudulent billing practices and ordered to pay restitution to the Carrier.

The Carrier’s evidence also indicates that the services billed did not conform to AMA CPT code 97750 for the service rendered, which specifically requires “direct one-on-one patient contact.” The evidence indicates that the four hours for which FCE’s were routinely billed by the provider failed to comply with that requirement.

A preponderance of the evidence is thus found to be contrary to the MFDRFD that Provider is entitled to reimbursement in the total amount of $612.00 for the FCE for date of service July 15, 2009 for Claimant’s compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled is reduced from $612.00 to $0.00.

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 (Date of Injury), Claimant was the employee of (Employer), Employer, and sustained a compensable injury.
  3. On (Date of Injury), Employer provided workers’ compensation insurance coverage through Texas Mutual Insurance Company.
  4. The Medical Fee Dispute Resolution (MFDR) Officer determined that Provider was entitled to additional reimbursement in the amount of $612.00 for the FCE of date of service July 15, 2009.
  5. Carrier delivered to Claimant 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.
  6. The services for which Provider billed under AMA CPT Code 97750 were not shown to be necessary and were billed at an excessive rate.
  7. No evidence was produced by the Provider to show the actual duration of the Functional Capacity Evaluation at issue.

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. A preponderance of the evidence is contrary to the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) that (Healthcare Provider 2) is entitled to additional reimbursement in the amount of $612.00 for an FCE for date of service July 15, 2009 for the compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled for that testing is reduced from $612.00 to $0.00.

DECISION

(Healthcare Provider 2) is not entitled to reimbursement in the amount of $612.00 for an FCE for date of service July 15, 2009 for the compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled for that testing is reduced from $612.00 to $0.00.

ORDER

Carrier is not liable for reimbursement at issue in this hearing in the amount of $612.00. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

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:

RICHARD J. GERGASKO

TEXAS MUTUAL INSURANCE COMPANY

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 1st day of October, 2013.

Robert Greenlaw
Hearing Officer

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 medical contested case hearing (MCCH) was held on May 2, 2013 to decide the following disputed issue:

Is a preponderance of the evidence contrary to the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) that VVA, M.D., P.A. is entitled to additional reimbursement in the amount of $381.11 for a urine drug screen for date of service September 20, 2011 for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Carrier (hereinafter “Carrier”) appeared and was represented by BJ, attorney. Respondent/Provider (hereinafter “Provider”) did not appear for the May 2, 2013 MCCH and did not respond to a 10-day letter from the Division. Claimant did not appear and her appearance was excused.

BACKGROUND INFORMATION

Although properly notified, Provider failed to appear for the contested case hearing scheduled for 2:00 p.m. on May 2, 2013. A letter advising that the hearing had convened and that the record would be held open for ten days to afford Provider the opportunity to respond and request that the hearing be rescheduled to permit that entity to present evidence on the disputed issue was mailed to Provider on May 6, 2013. Provider failed to respond to the Division’s 10-day letter and, on May 21, 2013, the record was closed.

The evidence presented in the hearing revealed that Provider sought payment from Carrier for urine drug testing of Claimant that it administered during a patient visit on September 20, 2011. In its request, Provider billed Carrier using Current Procedural Terminology (CPT) Codes. The source of this medical fee dispute case appears to derive from Provider’s multiple billing submissions under the following CPT Codes – 80299 (“QUANTITATION OF DRUG”) and 83925 (“OPIATES DRUG & METABOLITES”). The evidence reflected that, in its first request for payment received by Carrier on October 24, 2011, Provider billed Carrier for two units under CPT Code 80299 and two units under CPT Code 83925. Apparently, on the same day, Provider submitted another request to Carrier, but, in this request, only one unit under CPT Code 80299 was billed. Provider’s initial request for payment was denied in full by Carrier. Provider requested reconsideration from Carrier on December 13, 2011. In its initial bill submission on reconsideration, Provider requested payment for two units each under CPT Codes 80299 and 83925. Shortly after this request was received, Provider submitted another request. In the later billing, Provider requested payment for two units under CPT Code 83925 and one unit under CPT Code 80299. The evidence reflects that Provider’s request for payment on reconsideration was also fully denied by Carrier. Provider sought relief through the Division’s Medical Fee Dispute Resolution (MFDR) section in order to obtain reimbursement from Carrier. Provider’s DWC Form-060 (“Medical Fee Dispute Resolution Request/Response”) was received by the Division on May 14, 2012.

Carrier put forth testimony in the hearing from RB, a Senior Dispute Analyst with Carrier. Mr. B’s testimony highlighted the considerable confusion caused by Provider’s multiple billing submissions and its failure to explain the relationship between the first and second requests. Mr. B’s testimony indicated that it was unclear as to whether the later billings from Provider were meant to be a part of the same bill or if they were different bills entirely. The only relationship between the bills appeared to be that they came from the same Provider, were for the same Claimant, and reflected the same date of service.

On January 24, 2013, the Division’s MFDR Officer issued a decision (“Medical Fee Dispute Resolution Findings and Decision” or MFDRFD) holding that Provider was entitled to reimbursement in the amount of $381.11 from Carrier. The MFDR Officer appeared to include Provider’s first and second billings on reconsideration as part of the same bill and, consequently, ordered reimbursement of three units under CPT Code 80299 and four units under CPT Code 83925.

Division Rule 134.203 (“Medical Fee Guideline for Professional Services”), provides as follows at subsection (e) –

“The MAR [maximum allowable reimbursement] for pathology and laboratory services not addressed in subsection (c)(1) of this section or in other Division rules shall be determined as follows:

  1. 125 percent of the fee listed for the code in the Medicare Clinical Fee Schedule for the technical component of the service; and,
  2. 45 percent of the Division established MAR for the code derived in paragraph (1) of this subsection for the professional component of the service.”

In accordance with the Rule above, the MFDR Officer calculated as follows the amount of the MAR for CPT Codes 80299 and 83925, respectively –

$19.27 x 1.25 x 3 units = $508.20

$27.38 x 1.25 x 4 units = $31.00

Carrier pointed to internal inconsistencies and material typographical errors within the MFDRFD.[1] The evidence presented by Carrier in the hearing was found to be persuasive that, based on the actual laboratory testing results in evidence for the urine drug screen at issue, Provider is only entitled to reimbursement for one unit under CPT Code 80299 and two units under CPT Code 83925. The correct calculation of MAR based on this evidence is as follows for CPT Codes 80299 and 83925, respectively –

$19.27 x 1.25 x 1 unit = $24.0875 (rounded up to $24.09)

$27.38 x 1.25 x 2 units = $68.46

A preponderance of the evidence is thus found to be contrary to the MFDRFD that Provider is entitled to reimbursement in the total amount of $381.11 for the urine drug screen for date of service September 20, 2011 for Claimant’s compensable injury of (Date of Injury). The amount of reimbursement to which Provider is entitled is reduced from $381.11 to $264.47.

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. Carrier 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, and sustained a compensable injury.
    3. On (Date of Injury), Employer provided workers’ compensation insurance coverage through Texas Mutual Insurance Company.
    4. The Medical Fee Dispute Resolution (MFDR) Officer determined that Provider was entitled to additional reimbursement in the amount of $381.11 for the urine drug screen of date of service September 20, 2011.
  2. The Division sent a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent to Provider at its address of record. That document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  3. As part of the determination on reimbursement in this case, the MFDR Officer determined in the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) that Provider was entitled to reimbursement from Carrier for three units under CPT Code 80299 (“QUANTITATION OF DRUG”) and four units under CPT Code 83925 (“OPIATES DRUG & METABOLITES”) as a result of the urine drug screen for date of service September 20, 2011.
  4. The maximum allowable reimbursement (MAR) pursuant to Division Rule 134.203(e) for three units under CPT Code 80299 is $72.27.
  5. The MAR pursuant to Division Rule 134.203(e) for four units under CPT Code 83925 is $136.92.
  6. Based on the laboratory testing results in evidence, Provider is only entitled to reimbursement from Carrier for one unit under CPT Code 80299 and two units under CPT Code 83925 for the urine drug screen for date of service September 20, 2011.
  7. The MAR pursuant to Division Rule 134.203(e) for one unit under CPT Code 80299 is $24.09.
  8. The MAR pursuant to Division Rule 134.203(e) for two units under CPT Code 83925 is $68.46.
  9. The MAR for three units under CPT Code 80299 ($72.27) plus the MAR for four units under CPT Code 83925 ($136.92) equals $209.19.
  10. The MAR for one unit under CPT Code 80299 ($24.09) plus the MAR for two units under CPT Code 83925 ($68.46) equals $92.55.
  11. $92.55 subtracted from $209.19 equals $116.64.
  12. Provider’s total reimbursement for the urine drug screen for the September 20, 2011 date of service is calculated by subtracting $116.64 from $381.11.
  13. Provider failed to appear for the May 2, 2013 medical contested case hearing (MCCH) and did not respond to the Division’s letter offering it the opportunity to have the hearing rescheduled.
  14. Provider did not have good cause for failing to appear at the MCCH of May 2, 2013.

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. A preponderance of the evidence is contrary to the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) that VVA, M.D., P.A. is entitled to additional reimbursement in the amount of $381.11 for a urine drug screen for date of service September 20, 2011 for the compensable injury of (Date of Injury). The amount of additional reimbursement to which Provider is entitled for that testing is reduced from $381.11 to $264.47.

DECISION

VVA, M.D., P.A.’s entitlement to additional reimbursement for a urine drug screen for date of service September 20, 2011 for the compensable injury of (Date of Injury) is reduced from $381.11 to $264.47.

ORDER

Carrier is liable for reimbursement at issue in this hearing in the amount of $264.47. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

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

RICHARD J. GERGASKO

TEXAS MUTUAL INSURANCE COMPANY

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 23rd day of May, 2013.

Jennifer Hopens
Hearing Officer

  1. On p. 3 of the MFDRFD, the MFDR Officer cites that Provider billed for “one” unit of CPT Code 80299 and “two” units under CPT Code 83925, but the Officer nonetheless ordered reimbursement for three and four units, respectively, under those CPT Codes. The $508.20 and $31.00 figures found above and on p. 4 of the MFDRFD appear to be typographical errors and should be, respectively, $72.27 and $136.92 instead. The $28.73 MAR calculation for CPT Code 82520 and the six instances of $102.68 as the MAR for CPT Codes 82145, 82055, 83840, 83992, 82205, and 80154 also appear to be typographical errors in the MFDRFD and do not reflect the reimbursement amounts actually ordered by the MFDR Officer under those CPT Codes. Carrier’s position in the hearing was that it was only challenging the reimbursement amounts under CPT Codes 80299 and 83925 ordered in the MFDRFD and not the amounts ordered under the other CPT Codes in the MFDRFD.

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 consolidated medical contested case hearing was held on May 23, 2011[1] with Hearing Officer KB presiding to decide the following disputed issue –

Is the preponderance of the evidence contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Petitioner, is not entitled to additional reimbursement for the compensable injury of (Date of Injury) in the amount of $127.32 for Gabapentin 400MG CAPSULE (90 Units & 21 Units) for dates of service November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010, in the amount $508.35 for Hydrocodone/APAP 10/325 TAB (240 Units & 56 Units) for dates of service August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010, and in the amount of $503.92 for Skelaxin 800MG TABLET (90 Units & 120 Units) for dates of service August 27, 2009, September 24, 2009, and October 22, 2009, and in the amount of $191.42 for Baclofen 20MG TABLET (90 Units & 21 Units) for dates of service October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010?

Hearing Officer KB left Division employment in November 2012. As a decision in this matter was pending at that time, the undersigned hearing officer was assigned to review the record and issue a decision based on the evidence presented. The undersigned hearing officer reopened the record on December 27, 2012 after noticing mathematical calculation errors in the amount in dispute, above, concerning Gabapentin 400MG Capsule (Gabapentin) and Baclofen 20MG TABLET (Baclofen). The hearing officer contacted the parties in order to propose amending the amounts in dispute related to these medications to correct the errors, as well as to provide the parties with an opportunity to file additional written arguments. The record closed effective January 9, 2013. After neither party offered any objection to the hearing officer’s proposed amendment of the amounts in dispute for Gabapentin and Baclofen in the issue, those amounts were changed from “$127.32” to “$234.23” for Gabapentin and from “$191.42” to “$191.31” in the amount corresponding to Baclofen.

PARTIES PRESENT

Petitioner, (Healthcare Provider), appeared and was represented by HK, attorney. Respondent, Texas Mutual Insurance Company, Carrier, appeared and was represented by BJ, attorney. Claimant did not appear and his attendance was excused.

BACKGROUND INFORMATION

The petitioner in this case is (Healthcare Provider), which dispenses medications within a medical facility and whose customer base is almost exclusively workers’ compensation patients.

This medical contested case hearing concerned whether (Healthcare Provider) is entitled to additional reimbursement for medication – Gabapentin, Hydrocodone, Skelaxin, and Baclofen – it dispensed to Claimant for treatment of his (Date of Injury) compensable injury.

The following table serves to outline the overall dispute between (Healthcare Provider) and Carrier in this case:

Table 1

Date(s) of Service (DOS)

Medication / No. of Units

(Healthcare Provider) Charge to Carrier

Carrier Reimbursement to (Healthcare Provider)

Amount in Dispute

11/19/2009,

12/26/2009,

01/21/2010

Gabapentin 400MG CAPSULE / 90 Units

$550.50 ($183.50 x 3)

$333.54 ($111.18 x 3)

$216.96 ($72.32 x 3)

12/18/2009

Gabapentin 400MG CAPSULE / 21 Units

$45.90

$28.63

$17.27

08/27/2009,

09/24/2009,

10/22/2009,

11/19/2009,

12/26/2009,

01/21/2010

Hydrocodone /APAP 10/325 TAB / 240 Units

$1238.40 ($206.40 x 6)

$749.52 ($124.92 x 6)

$488.88 ($81.48 x 6)

12/18/2009

Hydrocodone /APAP 10/325 TAB / 56 Units

$51.30

$31.83

$19.47

08/27/2009

Skelaxin 800MG TABLET / 90 Units

$459.00

$331.02

$127.98

09/24/2009,

10/22/2009

Skelaxin 800MG TABLET / 120 Units

$1,221.40 ($610.70 x 2)

$845.46 ($422.73 x 2)

$375.94 ($187.97 x 2)

10/22/2009,

11/19/2009,

12/26/2009,

01/21/2010

Baclofen 20MG TABLET / 90 Units

$460.00 ($115.00 x 4)

$280.44 ($70.11 x 4)

$179.56 ($44.89 x 4)

12/18/2009

Baclofen 20MG TABLET / 21 Units

$32.10

$20.35

$11.75

The evidence presented in the hearing indicated that the reimbursement amount Carrier paid to (Healthcare Provider) for each of these medications was based on Carrier’s calculation of a reasonable and customary fee for the medications. After (Healthcare Provider)’s requests for reconsideration of the reimbursement amounts were denied by Carrier, (Healthcare Provider) sought relief through the Division’s Medical Fee Dispute Resolution (MFDR) section in order to obtain additional reimbursement from Carrier.

On January 12, 2011, the Division’s MFDR Officer issued a decision (“Medical Fee Dispute Resolution Findings and Decision” or MFDRFD) holding that (Healthcare Provider) was not entitled to the additional reimbursement at issue from Carrier. A fair reading of the MFDRFD indicates that the Division was not provided with sufficient evidence to substantiate (Healthcare Provider)’s usual and customary (U&C) charge for the medications at issue. Following the adverse decision from MFDR, (Healthcare Provider) requested a medical contested case hearing (MCCH) to resolve the fee question in this case.

An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. (Texas Labor Code §408.021). The term "health care" includesa prescription drug, medicine, or other remedy. (Texas Labor Code §401.011(19)(E)). The commissioner of the Division of Workers’ Compensation is directed by statute to adopt a fee schedule for pharmacy and pharmaceutical services that will provide reimbursement rates that are fair and reasonable; assure adequate access to medications and services for injured workers; and minimize costs to employees and insurance carriers. (Texas Labor Code §408.028(f)). The commissioner adopted reimbursement methodology for prescription drugs in Rule 134.503. The current version of this rule (“Pharmacy Fee Guideline”) went into effect on October 23, 2011.

Pursuant to the version of Rule 134.503 in effect at the time of the dates of service at issue in this case[2], the maximum allowable reimbursement (MAR) for prescription drugs was the lesser of the provider’s U&C charge for the same or similar service or a fee established by formulas based on the average wholesale price (AWP) determined by utilizing a nationally recognized pharmaceutical reimbursement system such as Redbook or First DataBank Inc. in effect on the day the prescription drug was dispensed. For generic drugs, the formula is AWP per unit multiplied by the number of units multiplied by 1.25, plus a $4.00 dispensing fee. See Rule 134.503(a)(2)(A), then in effect. The evidence presented in the hearing revealed that the prescription medications at issue in this case are generic drugs. The evidence also revealed that there is no contract between (Healthcare Provider) and Carrier, so Rule 134.503(a)(3), then in effect, does not apply to the facts of this case.

On December 11, 2003, RR, the Executive Director of the Texas Workers’ Compensation Commission, issued Advisory 2003-21 to address the determination of a pharmacy’s U&C charge for prescription drugs. In part, the Advisory states:

The Commission’s pharmacy prescription pricing rule is based, in part, on several important provisions concerning health care provider charges. First, fee guidelines are based, in part, on a provision that payment may not be in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual’s behalf (Texas Labor Code Section 413.011(d)). Also, “[a] health care provider commits an offense if the person knowingly charges an insurance carrier an amount greater than that normally charged for similar treatment to a payor outside the workers’ compensation system, except for mandated or negotiated charges” (Texas Labor Code §413.043(a)).

Parties requesting medical dispute resolution should ensure that they abide by the statute and rule references outlined above. The Commission’s Medical Dispute Resolution Section has indicated that parties filing a dispute have the burden of proof to support their position for advocating additional reimbursement. The burden of proof includes production of sufficient evidence to support that the reimbursement requested is in accordance with the factors listed in §413.011(b) of the Texas Workers’ Compensation Act.

(Healthcare Provider) has the burden to establish its entitlement to the additional reimbursement it seeks. In support of its contention that it is entitled to the reimbursement at issue, (Healthcare Provider)’s Pharmacist in Charge, TH, provided an affidavit that was admitted into evidence in the hearing. Mr. H’s April 29, 2011 affidavit indicates that (Healthcare Provider) makes no distinction between AWP and its U&C charges to avoid any discrepancy. (Healthcare Provider) also furnished literature and pricing information from Rx30, a professional billing and pricing hardware and software program that (Healthcare Provider) utilizes. The evidence presented in the hearing included an e-mail from MP, an employee of Rx30, who indicated that Rx30 does not calculate AWP itself, but, rather, it frequently obtains average wholesale pricing information for medications from First DataBank, Inc., a nationally recognized pharmaceutical reimbursement system. MP’s e-mail indicated that AWPs may vary if sources other than First DataBank, Inc. are used. Though the evidence revealed that (Healthcare Provider) does offer a discount to customers who pay for their medications in cash, the evidence also indicated that the percentage of such customers is an extremely small one, equating to less than .0025% of (Healthcare Provider)’s quarterly business.

According to a document on Rx30 letterhead, the AWP for Gabapentin 400MG CAPSULE on the November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010 dispensing dates was 1.5959. The following shows the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for this medication for 90 and 21 units, respectively:

$1.5959 (AWP) x 90 (# of Units) = $143.63; $143.63 x 1.25 = $179.54 (rounded up from $179.5375)

$179.54 + $4.00 (dispensing fee) = $183.54

$1.5959 (AWP) x 21 (# of Units) = $33.51 (rounded down from 33.5139); $33.51 x 1.25 = $41.89 (rounded up from $41.8875)

$41.89 + $4.00 (dispensing fee) = $45.89

The dispensing records from (Healthcare Provider) for this medication for the period from November 17, 2009 through January 21, 2010 were persuasive in establishing that (Healthcare Provider)’s U&C charge for 90 units of the drug was $183.50 during the period at issue. As the evidence was sufficient for (Healthcare Provider) to establish its U&C charge for 90 units of the Gabapentin 400MG CAPSULE and that such U&C charge was the lesser of the Rule 134.503(a)(2)(A) MAR formula, (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $216.96. (Healthcare Provider)’s $45.90 charge for 21 units of this drug on December 18, 2009 was found to be $ 0.01 greater than the 134.503(a)(2)(A) MAR calculation. Based on the evidence presented, (Healthcare Provider) is entitled to $17.26 (the difference between the $45.89 MAR and Carrier’s reimbursement of $28.63) for 21 units of Gabapentin 400MG CAPSULE for the December 18, 2009 date of service.

With regard to the Hydrocodone/APAP 10/325 TAB, (Healthcare Provider) presented a document with Rx30 letterhead indicating that the AWP for this medication on the dates at issue was 0.675. As laid out in the table on p. 3, above, the amount (Healthcare Provider) charged Carrier for 240 units of the medication was $206.40 and, for 56 units, it charged Carrier $51.30.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for this medication for 240 and 56 units, respectively:

$0.675 (AWP) x 240 (# of Units) = $162.00; $162.00 x 1.25 = $202.50

$202.50 + $4.00 (dispensing fee) = $206.50

$0.675 (AWP) x 56 (# of Units) = $37.80; $37.80 x 1.25 = $47.25

$47.25 + $4.00 (dispensing fee) = $51.25

Though there was some indication that (Healthcare Provider) may have rounded down the overall product of the Rule 134.503(a)(2)(A) MAR calculation in its calculation for 240 units of Hydrocodone/APAP 10/325 TAB, the dispensing records from (Healthcare Provider) for this medication for the period from August 27, 2009 through January 23, 2010 were persuasive in establishing that its U&C charge for 240 units of the drug was $206.40 during the period at issue. As the evidence was sufficient for (Healthcare Provider) to establish its U&C charge for the Hydrocodone/APAP 10/325 TAB and that such U&C charge was the lesser of the Rule 134.503(a)(2)(A) MAR formula, (Healthcare Provider) is found to be entitled to additional reimbursement in the amount of $488.88. (Healthcare Provider)’s $51.30 charge for 56 units of this drug was found to be $ 0.05 greater than the 134.503(a)(2)(A) MAR calculation. Based on the evidence presented, (Healthcare Provider) is entitled to $19.42 (the difference between the $51.25 MAR and Carrier’s reimbursement of $31.83) for 56 units of the Hydrocodone/APAP 10/325 TAB for the December 18, 2009 date of service.

The evidence presented in the hearing was insufficient to establish the AWP and U&C for the following medication at issue – Skelaxin 800MG. Consequently, (Healthcare Provider) is not entitled to additional reimbursement in the amount of $503.92 for that medication.

(Healthcare Provider) presented evidence in the hearing to indicate that, according to a document with Rx30 letterhead, the AWP for Baclofen 20MG Tablet on the October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010 dispensing dates was 0.9867. These drugs were dispensed under NDC #00-832102500. The December 18, 2009 date of service was dispensed under NDC #00-603240721 and a record from Rx30 indicates that the AWP for the medication under that NDC identifier and date of service was 1.0706.

The following indicates the calculation of MAR pursuant to Rule 134.503(a)(2)(A) for the 90 units of this medication dispensed on October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010 –

$0.9867 (AWP) x 90 (# of Units) = $88.803 (rounded down to $88.80); $88.80 x 1.25 = $111.00

$111.00 + $4.00 (dispensing fee) = $115.00

The calculation of MAR pursuant to Rule 134.503(a)(2)(A) for the 21 units of this medication dispensed on December 18, 2009 is as follows –

$1.0706 (AWP) x 21 (# of Units) = $22.4826 (rounded down to $22.48); $22.48 x 1.25 = $28.10

$28.10 + $4.00 (dispensing fee) = $32.10

Following a careful review of the evidence presented, (Healthcare Provider) established by a preponderance of the evidence that it is entitled to additional reimbursement in the total amount of $191.31 for the Baclofen dispensed on dates of service October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010. The evidence, particularly the (Healthcare Provider) dispensing records for the period of October 8, 2009 through January 28, 2010 for this medication, was persuasive in showing that (Healthcare Provider)’s U&C charge for both 90 and 21 units of this medication is the same as the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.

Based on the evidence presented in the hearing, (Healthcare Provider) established entitlement to additional reimbursement in the total amount of $933.83.

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 at the May 23, 2011 hearing:
    1. A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
    2. B.On (Date of Injury), Claimant was an employee of (Employer).
    3. Claimant sustained a compensable injury on (Date of Injury).
    4. The Medical Fee Dispute Resolution Officer determined that the provider is not entitled to reimbursement in the amount described by the hearing officer in the issues.
  • Respondent delivered to Petitioner 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 version of Rule 134.503 in effect from March 14, 2004 through October 22, 2011 applies in this case.
  • On November 19, 2009, December 26, 2009, and January 21, 2010, (Healthcare Provider) dispensed 90 units of Gabapentin 400MG CAPSULE to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $550.50 ($183.50 x 3) for this medication.
  • On December 18, 2009, (Healthcare Provider) dispensed 21 units of Gabapentin 400MG CAPSULE to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $45.90 for this medication.
  • On August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 26, 2009 and January 21, 2010, (Healthcare Provider) dispensed 240 units of Hydrocodone/APAP 10/325 TAB to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $1,238.40 ($206.40 x 6) for this medication.
  • On December 18, 2009, (Healthcare Provider) dispensed 56 units of Hydrocodone/APAP 10/325 TAB to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $51.30 for this medication.
  • On August 27, 2009, (Healthcare Provider) dispensed 90 units of Skelaxin 800MG TABLET to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $459.00 for this medication.
  • On September 24, 2009 and October 22, 2009, (Healthcare Provider) dispensed 120 units of Skelaxin 800MG TABLET to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $1,221.40 ($610.70 x 2) for this medication.
  • On October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010, (Healthcare Provider) dispensed 90 units of Baclofen 20MG Tablet to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $460.00 ($115.00 x 4) for this medication.
  • On December 18, 2009, (Healthcare Provider) dispensed 21 units of Baclofen 20MG Tablet to Claimant for his compensable injury of (Date of Injury); (Healthcare Provider) billed Carrier a total of $32.10 for this medication.
  • The prescription medications for which additional reimbursement was sought in this case are generic drugs.
  • There was no negotiated or contracted amount payable pursuant to Rule 134.503(a)(3).
  • (Healthcare Provider) established the average wholesale price (AWP) of Gabapentin 400MG CAPSULE, Hydrocodone/APAP 10/325 TAB, and Baclofen 20MG TABLET in this case on the dispensing dates in dispute by providing information from Rx30, a professional billing and pricing hardware and software program. Rx30 obtained this data from a nationally recognized pharmaceutical reimbursement system (First DataBank, Inc.).
  • The evidence was insufficient to show the AWP or (Healthcare Provider)’s usual and customary (U&C) charge for 90 units of Skelaxin 800MG TABLET dispensed to Claimant on August 27, 2009; (Healthcare Provider) is therefore not entitled to additional reimbursement in the amount of $127.98 for this medication.
  • The evidence was insufficient to show the AWP or (Healthcare Provider)’s U&C charge for 120 units of Skelaxin 800MG TABLET dispensed to Claimant on September 24, 2009 and October 22, 2009; (Healthcare Provider) is therefore not entitled to additional reimbursement in the amount of $375.94 for this medication.
  • For the Gabapentin 400MG CAPSULE, the AWP on the dates of service in dispute (November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010) was 1.5959 pursuant to the data furnished by Rx30.
  • For the Hydrocodone/APAP 10/325 TAB, the AWP on the dates of service in dispute (August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010) was 0.675 pursuant to the data furnished by Rx30.
  • For the Baclofen 20MG Tablet, the AWP under NDC #00-832102500 on the October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010 dispensing dates was 0.9867 pursuant to the data furnished by Rx30.
  • For the Baclofen 20MG Tablet, the AWP under NDC #00-603240721 on the December 18, 2009 dispensing date was 1.0706 pursuant to the data furnished by Rx30.
  • (Healthcare Provider)’s U&C charge for 90 units of Gabapentin 400MG CAPSULE on the dates of service in dispute (November 19, 2009, December 26, 2009, and January 21, 2010) was $183.50.
  • (Healthcare Provider)’s U&C charge for 21 units of Gabapentin 400MG CAPSULE on December 18, 2009 was $45.90.
  • (Healthcare Provider)’s U&C charge for 240 units of Hydrocodone/APAP 10/325 TAB on the dates of service in dispute (August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010) was $206.40.
  • (Healthcare Provider)’s U&C charge for 56 units of Hydrocodone/APAP 10/325 TAB on December 18, 2009 was $51.30.
  • (Healthcare Provider)’s U&C charge for 90 units of Baclofen 20MG Tablet on the dates of service in dispute (October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010) was $115.00.
  • (Healthcare Provider)’s U&C charge for 21 units of Baclofen 20MG Tablet on December 18, 2009 was $32.10.
  • For the 90 units of Gabapentin 400MG CAPSULE dispensed on November 19, 2009, December 26, 2009, and January 21, 2010, Carrier reimbursed (Healthcare Provider) a total of $333.54 ($111.18 x 3).
  • For the 21 units of Gabapentin 400MG CAPSULE dispensed on December 18, 2009, Carrier reimbursed (Healthcare Provider) a total of $28.63.
  • For the 240 units of Hydrocodone/APAP 10/325 TAB dispensed on August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010, Carrier reimbursed (Healthcare Provider) a total of $749.52 ($124.92 x 6).
  • For the 56 units of Hydrocodone/APAP 10/325 TAB dispensed on December 18, 2009, Carrier reimbursed (Healthcare Provider) a total of $31.83.
  • For the 90 units of Baclofen 20MG Tablet dispensed on October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010, Carrier reimbursed (Healthcare Provider) a total of $280.44 ($70.11 x 4).
  • For the 21 units of Baclofen 20MG Tablet dispensed on December 18, 2009, Carrier reimbursed (Healthcare Provider) a total of $20.35.
  • The maximum allowable reimbursement (MAR) for 90 units of Gabapentin 400MG CAPSULE on the dates of service in dispute (November 19, 2009, December 26, 2009, and January 21, 2010) is $183.50, which is $.04 less than the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  • The MAR for 21 units of Gabapentin 400MG CAPSULE on the December 18, 2009 date of service is $45.89, which is equal to the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  • The MAR for 240 units of Hydrocodone/APAP 10/325 TAB on the dates of service in dispute (August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010) was $206.40, which is $0.10 less than the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  • The MAR for 56 units of Hydrocodone/APAP 10/325 TAB on the December 18, 2009 date of service was $51.25, which is equal to the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  • The MAR for 90 units of Baclofen 20MG Tablet on the dates of service in dispute (October 22, 2009, November 19, 2009, December 26, 2009, and January 21, 2010) was $115.00, which is equal to the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  • The MAR for 21 units of Baclofen 20MG Tablet on the December 18, 2009 date of service is $32.10, which is equal to the amount elicited from the Rule 134.503(a)(2)(A) formula calculation.
  • 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. A preponderance of the evidence is contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Petitioner, is not entitled to additional reimbursement for the compensable injury of (Date of Injury) in the amount of $234.22 for Gabapentin 400MG CAPSULE (90 Units & 21 Units) for dates of service November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010, in the amount $508.30 for Hydrocodone/APAP 10/325 TAB (240 Units & 56 Units) for dates of service August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010, and in the amount of $191.31 for Baclofen 20MG TABLET (90 Units & 21 Units) for dates of service October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010.
    4. A preponderance of the evidence is not contrary to the Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Petitioner, is not entitled to additional reimbursement in the amount of $.01 for Gabapentin 400MG CAPSULE (21 Units) for the December 18, 2009 date of service, for $.05 for Hydrocodone/APAP 10/325 TAB (56 Units) for the December 18, 2009 date of service, or in the amount of $503.92 for Skelaxin 800MG TABLET (90 Units & 120 Units) for dates of service August 27, 2009, September 24, 2009, and October 22, 2009.

    DECISION

    (Healthcare Provider), Petitioner, is entitled to additional reimbursement for the compensable injury of (Date of Injury) in the amount of $234.22 for Gabapentin 400MG CAPSULE (90 Units & 21 Units) for dates of service November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010, in the amount $508.30 for Hydrocodone/APAP 10/325 TAB (240 Units & 56 Units) for dates of service August 27, 2009, September 24, 2009, October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010, and in the amount of $191.31 for Baclofen 20MG TABLET (90 Units & 21 Units) for dates of service October 22, 2009, November 19, 2009, December 18, 2009, December 26, 2009, and January 21, 2010.

    (Healthcare Provider) is not entitled to additional reimbursement in the amount of $.01 for Gabapentin 400MG CAPSULE (21 Units) for the December 18, 2009 date of service, for $.05 for Hydrocodone/APAP 10/325 TAB (56 Units) for the December 18, 2009 date of service, or in the amount of $503.92 for Skelaxin 800MG TABLET (90 Units & 120 Units) for dates of service August 27, 2009, September 24, 2009, and October 22, 2009.

    ORDER

    Carrier is liable for additional reimbursement in the amount of $933.83 in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

    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, PRESIDENT

    6210 EAST HIGHWAY 290

    AUSTIN, TEXAS 78723

    Signed this 18th day of January, 2013.

    Jennifer Hopens
    Hearing Officer

    1. This fee dispute was heard in a consolidated medical contested case hearing along with the fee disputes in (Sequence 02) and (Sequence 03).

    2. The version of Rule 134.503 (“Reimbursement Methodology”) applicable to this case was in effect from March 14, 2004 to October 22, 2011.

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