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At a Glance:
Title:
453-02-0130-m4
Date:
August 21, 2002
Status:
Medical Fees

453-02-0130-m4

August 21, 2002

DECISION AND ORDER

I. Statement of the Case

The claimant, ___,a resident of Dallas, Texas, sustained a compensable workers’ compensation injury on__________. The provider in this case, Oxymed, Inc. (Oxymed), also located in Dallas, provided medical services to the claimant, including a Miami J cervical collar. Oxymed requested reimbursement in the amount of $400.00 from Liberty Mutual Fire Insurance Company (Liberty) for the cervical collar. Liberty determined that $252.48 was a fair and reasonable amount for the collar and reimbursed Oxymed for that amount. Oxymed, standing on its claim that it should be reimbursed for the entire $400.00, requested dispute resolution from the Texas Workers’ Compensation Commission’s Medical Review Division (the Division). The Division found in Oxymed’s favor and ordered Liberty to reimburse the remaining $2.[1] Liberty appealed the Division’s decision to the State Office of Administrative Hearings. Therefore, $147.52 is the amount in dispute in this case.

The hearing on Liberty’s appeal convened on July 25, 2002. Liberty appeared through its counsel, Shannon Butterworth. Oxymed was represented by its counsel, Scott Wilkerson. The staff of the Texas Workers’ Compensation Commission waived appearance and did not appear. The parties did not contest notice or jurisdiction, and those matters are addressed in the findings of fact and conclusions of law below. The record closed on July 25, 2002.

Section §413.011(b) of the Texas Labor Code provides in pertinent part,

Guidelines for medical services fees must be fair and reasonable and designed to ensure the quality of medical care and to achieve effective medical cost control. The guidelines may not provide for payment of a fee 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.

Liberty demonstrated that the amount it paid to Oxymed is a fair and reasonable amount for the cervical collar. It produced evidence indicating that on four separate occasions for four separate claimants in the same geographical area as ___,it had paid to Oxymed amounts ranging from $203.22 to $253.44 for the Miami J cervical collar, and Oxymed’s owner, Emil Cerullo, testified he accepted those amounts, although he had requested the full $400.00 reimbursement in each case. He also testified he was not satisfied with the amounts Liberty paid him in those instances, but that because of the expense involved in appealing relatively minimal amounts, he chose not to appeal in any of the four cases.

It is true that evidence presented to the Division and included in the record of this case indicates that other carriers reimbursed Oxymed for the cervical collar at amounts ranging from $340.00 to the full $400.00. However, with one exception for a claimant in Grand Prairie, Texas, it is impossible to tell from that evidence if the claimants were in the same or a similar geographical area or if they were in the same or a similar medical community as in this case -- factors that under the right circumstances might have justified a higher reimbursement here - and Oxymed introduced no evidence to support or elaborate on those higher reimbursements.

Based on this record, the Administrative Law Judge finds that the Division’s decision should not be upheld, and that Liberty should not be required to reimburse Oxymed for the additional $147.52 in dispute.

II. Findings of Fact

  1. The claimant,___, a resident of Dallas, Texas, sustained a compensable workers’ compensation injury on________. The injury was covered by Liberty Mutual Fire Insurance Company (Liberty).
  2. The provider, Oxymed, Inc. (Oxymed) is also located in Dallas.
  3. Oxymed provided medical services to ___,including a Miami J cervical collar.
  4. Oxymed requested reimbursement in the amount of $400.00 from Liberty for the cervical collar provided to ___.
  5. Liberty determined that $252.48 was a fair and reasonable amount for the cervical collar and reimbursed Oxymed for that amount.
  6. Oxymed requested dispute resolution from the Texas Workers’ Compensation Commission’s Medical Review Division (the Division) on the grounds that it was entitled to be reimbursed $400.00 for the cervical collar.
  7. The Division found in Oxymed’s favor and ordered Liberty to reimburse the remaining $147.52.
  8. Liberty appealed the Division’s decision to the State Office of Administrative Hearings.
  9. The staff of the Texas Workers’ Compensation Commission issued a notice of hearing on September 20, 2001, notifying the parties of a hearing on Liberty’s appeal.
  10. The hearing was held on July 25, 2002. Liberty and Oxymed appeared and participated in the hearing. The staff of the Commission waived appearance and did not appear.
  11. On four separate occasions for four separate claimants in the same geographical area as ___Liberty had paid to Oxymed amounts ranging from $203.22 to $253.44 for the Miami J cervical collar.
  12. Oxymed accepted the amounts described in the previous finding as reimbursement for the Miami J cervical collar.
  13. Oxymed introduced no evidence justifying a higher reimbursement for the Miami J cervical collar at issue in this case.

III. Conclusions of Law

  1. The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over the issue presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
  2. The State Office of Administrative Hearings has jurisdiction over all matters related to the hearing in this case, including the issuance of this decision and order, pursuant to Tex. Gov’t Code Ann.ch. 2003 and pursuant to §413.031(d) of the Act.
  3. Notice of the hearing was proper and timely, as required by the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001.
  4. The reimbursement paid by Liberty to Oxymed for the Miami J collar for ___was fair and reasonable as contemplated by Tex. Lab. Code Ann. §413.011(b).
  5. Oxymed should not be further reimbursed for the Miami J cervical collar provided to___.

ORDER

IT IS, THEREFORE, ORDERED that Liberty Mutual Insurance Company shall not be required to reimburse Oxymed, Inc., for an additional $147.52 for a Miami J cervical collar provided to the claimant ___.

Signed August 21, 2002.

CATHLEEN PARSLEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Medical Dispute Resolution Findings and Decision #M4-01-1827-01.
End of Document
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