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At a Glance:
Title:
453-01-3716-m5
Date:
September 17, 2002
Status:
Retrospective Medical Necessity

453-01-3716-m5

September 17, 2002

DECISION AND ORDER

This is a dispute over reimbursement for work hardening services and document copying. The amounts in dispute are $8,601.60 for the work hardening services and $76.00 for the document copying, for a total of $8,677.60.[1]

The Administrative Law Judge concludes the Back & Joint Clinic did not prove the work hardening program was medically necessary, but did prove it was entitled to reimbursement for the document copying. He orders additional reimbursement of $76.00 plus interest.

I. Discussion

The Claimant, a custodian for the Bryan Independent School District (Bryan ISD), sustained a compensable injury___________. She was first seen by Sam Liscum, D.C. of the Back & Joint Clinic, on May 18, 1999. After conducting a Functional Capacity Evaluation on August 24, 1999, Dr. Liscum recommended the Claimant enter a work hardening program.

The Claimant’s work hardening program began August 30 and ended October 19, 1999. Bryan ISD refused to reimburse the Back & Joint Clinic for the program and for certain other services, whereupon the Clinic filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (TWCC or the Commission). The Commission’s Medical Review Division (MRD) found the Bryan ISD had not provided Explanations of Benefits (EOBs) for some CPT codes on some dates of service, and ordered Bryan ISD to reimburse the Back & Joint Clinic for those services. It declined to order reimbursement for the rest of the work hardening services, however, finding the Clinic had not established their medical necessity.

The MRD also declined to order reimbursement for two sets of medical documents copied by the Back & Joint Clinic. Those documents were copied on July 28 and August 27, 1999.

Work Hardening Services

“Work hardening” is

a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. Work Hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured worker. . . .

TWCC 1996 Medical Fee Guideline, p. 37

In his August 24, 1999, FCE, Dr. Liscum observed,

There appears to be evidence of significant anxiety in the patient. There appears to be evidence of significant signs of depression in the patient.

Ex. 1, p. 121

Dr. Liscum described the Claimant as having “significant psychosocial dysfunctions.” Physically, her symptoms consisted of low back pain with tingling down her right leg. She appeared to have no significant problems with pain intensity, personal care, lifting, walking, standing, sleeping, sex life, social life, and traveling.” Dr. Liscum concluded the Claimant was a good candidate” for a work hardening program. Ex. 1 at 121-27.

Bryan ISD approved individual psychotherapy and biofeedback for the Claimant because of her psychological condition. Ex. 1, pp. 24, 30. She attended both, though she apparently was not diligent about the biofeedback sessions. Ex. 1, pp. 342-57.

The evidence does not support the medical necessity of the work hardening program for the Claimant. At the time the program began, although she had some physical symptoms, she had no serious difficulty with work-related tasks such as standing, lifting, and walking, which were activities performed during the program. See Ex. 1, p. 133. Although she was depressed, that condition was addressed through individual psychotherapy. The record does not show the need for a highly structured, goal-oriented, individualized, interdisciplinary treatment program such as work hardening.

The Back & Joint Clinic argued its request should be granted because the MRD ordered Bryan ISD to pay for some of the work hardening services, and the sessions were identical or similar to one another. The MRD’s decision, however, was based on the fact that Bryan ISD had failed to provide EOBs for those CPT codes. That is not true of the services at issue in this case.

The ALJ denies the Back & Joint Clinic’s request for additional reimbursement for work hardening services.

Document Copying

The MRD denied reimbursement for the copies of medical records because the Dispute Resolution Officer could not determine what records were copied. The Back & Joint Clinic pointed to explanations of each tucked away in the certified record, however. One set of medical records was sent to Gregory LeBleu, M.D. for a TWCC-ordered medical examination and the other was sent to Marcy Halterman-Cox, D.C. for a designated doctor examination. Ex. 1, pp. 160, 163-64.

Bryan ISD argued it should not be required to reimburse the Back & Joint Clinic for those copying costs because 28 Tex. Admin. Code (TAC) §133.106(d) states,

The health care provider will not charge the commission for copies of any requested or required documents.

The Back & Joint Clinic is not attempting to charge the Commission for the copies, however. It is attempting to charge the carrier, which it is entitled to under 28 TAC §133.106(a), as long as the fees are fair and reasonable. The amount of these fees were fair and reasonable; there was no argument to the contrary.

The ALJ orders Bryan ISD to reimburse the Back & Joint Clinic $76.00 for the copies of medical records made July 28 and August 27, 1999.

II. Findings of Fact

  1. The Claimant, a custodian for the Bryan Independent School District (Bryan ISD), sustained a compensable injury ___________. The Claimant was first seen by Sam Liscum, D.C. of the Back & Joint Clinic, on May 18, 1999.
  2. After conducting a Functional Capacity Evaluation on August 24, 1999, Dr. Liscum recommended the Claimant enter a work hardening program.
  3. The Claimant’s work hardening program began August 30 and ended October 19, 1999.
  4. Bryan ISD refused to reimburse the Back & Joint Clinic for the work hardening program and for certain other services, whereupon the Clinic filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (TWCC or the Commission).
  5. The Commission’s Medical Review Division (MRD) found Bryan ISD had not provided Explanations of Benefits (EOBs) for some CPT codes on some dates of service, and ordered Bryan ISD to reimburse the Back & Joint Clinic for those services. It declined to order reimbursement for the rest of the work hardening services, however, finding the Clinic had not established their medical necessity.
  6. The MRD also declined to order reimbursement for two sets of medical documents copied by the Back & Joint Clinic. Those documents were copied on July 28 and August 27, 1999.
  7. The Back & Joint Clinic requested a hearing before SOAH; Bryan ISD did not.
  8. Notice of the hearing was sent to the parties August 6, 2001.
  9. 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.
  10. The hearing was held September 3, 2002, before the undersigned Administrative Law Judge (ALJ), with representatives of both parties participating.
  11. At the time the program began, although she had some physical symptoms, the Claimant had no serious difficulty with work-related tasks such as standing, lifting, and walking, which were activities performed during the program.
  12. Although the Claimant was depressed, that condition was addressed through individual psychotherapy.
  13. The Claimant did not need a highly structured, goal-oriented, individualized, interdisciplinary treatment program such as work hardening.
  14. Bryan ISD provided EOBs for the services at issue in this case.
  15. One set of disputed medical records was sent to Gregory LeBleu, M.D. for a TWCC-ordered medical examination and the other was sent to Marcy Halterman-Cox, D.C. for a designated doctor examination.
  16. The Back & Joint Clinic is not attempting to charge the Commission for the copies; it is attempting to charge the carrier.
  17. The copying fees charged by the Back & Joint Clinic were fair and reasonable.

III. 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. The Back & Joint Clinic has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  5. The Back & Joint Clinic did not meet its burden of proving it was entitled to additional reimbursement of $8, 601.60 for work hardening services provided to the Claimant.
  6. The Commission’s rule at 28 TAC §133.106(d) does not preclude the Back & Joint Clinic from charging Bryan ISD for copying costs.
  7. The Back & Joint Clinic is entitled to reimbursement from Bryan ISD for the $76.00 of document copying costs under 28 TAC §133.106.

ORDER

IT IS, THEREFORE, ORDERED that Bryan Independent School District reimburse the Back & Joint Clinic the amount of $76.00, plus interest, for document copying costs incurred July 28 and August 27, 1999. All other requests for reimbursement are denied.

Signed September 17th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. At the hearing, the parties stated the amount in dispute was $8,676.60, but it appears the cost of the document copying was $76.00 rather than $75.00.
End of Document
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