Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-3489-m5
Date:
July 2, 2002
Status:
Retrospective Medical Necessity

453-01-3489-m5

July 2, 2002

DECISION AND ORDER

This is a dispute over payment for office visits, chiropractic treatments, and related charges. The Administrative Law Judge concludes Ace Insurance Company of Texas (the Carrier) should reimburse Richard G. Young, D.C., the health care provider, for the amounts the Carrier approved in its Explanations of Benefits (EOBs), but not for any additional amounts.

I. Discussion

The Claimant sustained a work-related injury to her back in _______After a period of fairly intense treatment by Dr. Young, she was declared to be at maximum medical improvement, with an impairment rating of five percent, in November of 1994. However, she continued receiving occasional treatments from Dr. Young, which the Carrier reimbursed, in the years that followed. In February of 1999, she suffered what she and Dr. Young considered to be a significant exacerbation of her condition, and received considerable treatment. The Carrier agreed to reimburse Dr. Young for some of that treatment. It then determined the Claimant’s condition was not related to the original injury and that her treatment was excessive, and declined further payment.

Dr. Young sought reimbursement of $3,375.00, for a number of dates of service from February 19, 1999, through November 29, 1999. The Carrier’s Explanations of Benefits (EOBs) recommended payment of $1,642.00. The parties agreed that the amount in dispute is $1,733.00 ($3,375.00 - 1,642.00 = $1,733.00). See Medical Review Division (MRD) Record (Dr. Young Ex. 1) at page 5. The MRD of the Texas Workers’ Compensation Commission (the Commission) did not order additional payments.

According to Dr. Young, the Carrier has actually sent him only two checks for the disputed dates of service, for a total of $420.00. There was some question in the ALJ’s mind as to whether the Carrier intended to pay the additional amount. If that is an issue, the ALJ concludes the Carrier is required to reimburse Dr. Young at least $1,642.00, plus any applicable interest, based on its EOBs and its agreement at the hearing that the amount in dispute is $1,733.00.

The billed charges for the services the Carrier agreed to reimburse were $1900.00. The $1,642.00 reimbursement figure was based on contractual or maximum-allowable-reimbursement (MAR) reductions to those billed charges. It was appropriate to reduce Dr. Young’s billed charges to those levels; Dr. Young did not argue otherwise.

The difference between the billed levels and the reimbursement levels, for the dates of service that the Carrier agreed to reimburse, is $258.00. When that figure is subtracted from $1,733.00, the amount truly remaining in dispute is $1,475.00.

With regard to that amount, the overriding questions are whether the treatment related to the original injury and, if so, whether the level of treatment was medically necessary. As the Appellant, Dr. Young had the burden of proving both those matters. The ALJ will not address the first , because he concludes Dr. Young did not prove the second. Of course, Dr. Young testified and believed his level of treatment was necessary. In a letter dated May 1, 2001, however, he stated one to six sessions with the chiropractor for exacerbations is not unreasonable . . . . Dr. Young Ex. 1, at page 10. Michael McGarrah, D.C., an independent chiropractor consulted by Dr. Young for the purpose of this proceeding, examined the Claimant and agreed additional care was necessary for her condition. He suggested she would likely require treatment on an average of one to two visits per month on an indefinite basis. He did not specifically address the dates of service at issue, however.

Although Dr. McGarrah observed the Claimant would need treatment with greater frequency during periods of exacerbation, neither he nor Dr. Young established what that frequency would be. Neither he nor Dr. Young discussed specific modalities that should be used. Neither refuted the Carrier’s specific objections, which were set out in the MRD Decision, to paying for those particular services.

Therefore, the ALJ concludes Dr. Young did not prove he should be reimbursed for any of the additional $1,733.00.

II. Findings of Fact

  1. The Claimant sustained a work-related injury to her back in _____________
  2. After a period of fairly intense treatment by Richard G. Young, D.C., the health care provider, she was declared to be at maximum medical improvement, with an impairment rating of five percent, in November of 1994.
  3. The Claimant continued receiving occasional treatments from Dr. Young, which the Carrier reimbursed, in the years that followed.
  4. In February of 1999, the Claimant suffered what she and Dr. Young considered to be a significant exacerbation of her condition, and received considerable treatment.
  5. Ace Insurance Company of Texas (the Carrier) agreed to reimburse Dr. Young for some of the treatment that began in February of 1999. It then determined the Claimant’s condition was not related to the original injury and that her treatment was excessive, and declined further payment.
  6. Dr. Young sought reimbursement of $3,375.00, for a number of dates of service from February 19, 1999, through November 29, 1999.
  7. The Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (the Commission) issued its decision in this matter June 8, 2001.
  8. Dr. Young filed a timely appeal of the MRD decision.
  9. Notice of the hearing was sent July 18, 2001.
  10. 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.
  11. The hearing was held May 28, 2002, with Administrative Law Judge Henry D. Card presiding and Dr. Young and the Carrier’s representative participating. The hearing was adjourned the same day.
  12. The Carrier’s Explanations of Benefits (EOBs) recommended payment of $1,642.00. The parties agreed that the amount in dispute is $1,733.00 ($3,375.00 - 1,642.00 = $1,733.00).
  13. The Carrier has actually sent Dr. Young only two checks for the disputed dates of service, for a total of $420.00.
  14. The billed charges for the services which the Carrier agreed to reimburse were $1900.00. The $1,642.00 reimbursement figure was based on contractual or maximum-allowable-reimbursement (MAR) reductions to those billed charges.
  15. It was appropriate to reduce Dr. Young’s billed charges to the contractual or MAR levels.
  16. The difference between the billed levels and the reimbursement levels, for the dates of service that the Carrier agreed to reimburse, is $258.00. When that figure is subtracted from $1,733.00, the amount truly remaining in dispute is $1,475.00.
  17. Dr. Young did not establish what the frequency of treatment should be during any periods of exacerbation of the Claimant’s injury.
  18. Dr. Young did not establish what treatment modalities were necessary during any periods of exacerbation of the Claimant’s injury.
  19. Dr. Young did not refute the Carrier’s specific objections, which were set out in the MRD Decision, to paying for the disputed services.

III. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
  2. The State Office of Administrative Hearings 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. Dr. Young has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. The Carrier is required to reimburse Dr. Young $1,642.00, plus any applicable interest, based on its EOBs and its agreement at the hearing that the amount in dispute is $1,733.00.
  6. Dr. Young did not prove he should be reimbursed for any of the additional $1,733.00.

ORDER

IT IS, THEREFORE, ORDERED that Ace Insurance Company of Texas shall reimburse Richard G. Young, D.C., the amount of $1,642.00, plus applicable interest, for services rendered to the Claimant from February 19, 1999, through November 29, 1999. That amount includes payments already made to Dr. Young by Ace Insurance Company of Texas for those dates of service. Ace Insurance Company of Texas shall not be required to reimburse Dr. Young for any additional billed charges for those dates of service.

Signed this 2nd day of July, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

End of Document
Top