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At a Glance:
Title:
453-01-2856-m5
Date:
February 7, 2002
Status:
Retrospective Medical Necessity

453-01-2856-m5

February 7, 2002

DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate for certain office visits and a functional capacity evaluation. _____ (Claimant) made office visits between October 26, 1999, and April 10, 2000, to various healthcare providers. One of the office visits included a functional capacity evaluation. Workers Healthcare Center (Provider) billed Nabisco, Inc. (Carrier) for these office visits. Carrier denied reimbursement to Provider for certain office visits between September 26, 1999 and April 10, 2000 asserting Claimant was seen by health providers other than the treating doctor without having the necessary referral from the treating doctor. The amount in controversy is $938.00.

Mark H. Sickles, representative of Nabisco, Inc. (Petitioner) appeared at the hearing after receiving proper notice. A representative for Respondent, Workers Healthcare Center, did not appear. The only evidence was presented by Petitioner. The ALJ finds Provider is not entitled to reimbursement by Carrier for medical procedures performed between September 26, 1999 and April 10, 2000.

I.

FINDINGS OF FACT

  1. Claimant, ____, suffered a compensable injury on_________.
  2. Alex Riley, D.C., is Claimant’s treating doctor.
  3. The only dates eligible for review in this dispute are September 26, 1999 through April 10, 2000.
  4. Provider billed Carrier $500.00 for CPT Code 97750FC performed on September 26, 1999. Margarita Chan, P.T., of Heights Therapy & Rehabilitation Center performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor.
  5. Provider billed Carrier $148.00 for CPT Code 99244 performed on September 26, 1999. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor.
  6. Provider billed Carrier $50.00 for CPT Code 99080 performed on September 26, 1999. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor.
  7. Provider billed Carrier $70.00 for CPT Code 99213 performed on November 29, 1999. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor. The Maximum Allowable Reimbursement amount reduced the billable amount to $48.00.
  8. Provider billed Carrier $70.00 for CPT Code 99213 performed on December 27, 1999. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor. The Maximum Allowable Reimbursement amount reduced the billable amount to $48.00.
  9. Provider billed Carrier $70.00 for CPT Code 99213 performed on January 24, 2000. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor. The Maximum Allowable Reimbursement amount reduced the billable amount to $48.00.
  10. Provider billed Carrier $70.00 for CPT Code 99213 performed on February 24, 2000. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor. The Maximum Allowable Reimbursement amount reduced the billable amount to $48.00.
  11. Provider billed Carrier $70.00 for CPT Code 99213 performed on March 23, 2000. The Maximum Allowable Reimbursement amount reduced the billable amount to $48.00. Carrier paid Provider $48.00.
  12. Provider billed Carrier $70.00 for CPT Code 99213 performed on April 10, 2000. John Bergeron, M.D., performed this medical procedure. Carrier denied payment citing service was provided by a health provider other than the treating doctor without the requisite approval or recommendation by the treating doctor. The Maximum Allowable Reimbursement amount reduced the billable amount to $48.00.
  13. For the procedures outlined in Findings of Facts Nos. 4-12, Provider billed Carrier a total of $1,118.00.
  14. For the procedures outlined in Findings of Facts Nos. 4-12, The Maximum Allowable Reimbursement amount reduced the billable amount to $986.00.
  15. For the procedures outlined in Findings of Facts Nos.4-12, Carrier reimbursed Provider a total amount of $48.00.
  16. Provider filed a Request for Medical Dispute Resolution with the Medical Review Division of the Texas Workers’ Compensation Commission (Commission), seeking reimbursement for the procedures outlined in Findings of Facts Nos.4-12.
  17. On March 26, 2001, the Commission’s Medical Review Division found Provider was entitled to reimbursement in the amount of $938.00 for the services outlined in Findings of Facts Nos. 4-12.
  18. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  19. Notice of the hearing was sent May 11, 2001.
  20. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  21. The hearing was held December 18, 2001, with ALJ Steven M. Rivas presiding with only a representative of the Carrier participating. The Provider did not make an appearance. The hearing was adjourned the same day.
  22. Carrier provided evidence disputing the findings of the Medical Review Division.
  23. No referral letters were forwarded to Carrier where healthcare providers other than the treating doctor performed medical services for Claimant.
  24. Provider is not entitled to additional reimbursement for the medical services outlined in Findings of Facts Nos. 4-12.

II. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann§ 2001.052.
  4. Carrier, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
  5. The treatment given to Claimant in Findings of Facts Nos. 4-12 was not approved or recommended by the treating doctor in compliance with Tex. Lab. Code Ann. § 408.021(c).
  6. Provider is not entitled to reimbursement from Carrier for medical procedures outlined in the above Findings of Facts Nos. 4-12.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Workers Healthcare Center, is not entitled to reimbursement of $938.00 from Carrier, Nabisco, Inc., for the medical treatment performed between September 26, 1999, to April 10, 2000.

Signed February 7, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

End of Document
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