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At a Glance:
Title:
453-02-0395-m4
Date:
November 19, 2002
Status:
Medical Fees

453-02-0395-m4

November 19, 2002

DECISION AND ORDER

Liberty Mutual Fire Insurance Company (Liberty Mutual) appealed the Findings and Decision issued by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) in a fee dispute case. The MRD Decision ordered Liberty Mutual Fire Insurance Company to remit $813.00, plus all accrued interest due at the time of payment toLinda Cornell, M.D., for providing chronic pain therapy to an injured worker.

Liberty Mutual asserted that the Dr. Cornell should be allowed to charge only $100.00 per hour for therapy billed under CPT code 97799-CP and a charge under 99361 should be denied as global to other services provided by Dr. Cornell. Dr. Cornell did not appear at hearing. The MRD staff also did not appear at the hearing. The Administrative Law Judge (ALJ) finds that Liberty Mutual showed by a preponderance of the evidence that Dr. Cornell was not entitled to additional reimbursement.

I. PROCEDURAL HISTORY, JURISDICTION, AND NOTICE

On September 9, 2002, Administrative Law Judge John H. Beeler convened the hearing at the William P. Clements Building, 301 W. 15th Street, Austin, Texas. Attorney Shannon Butterworth represented Liberty Mutual; no one represented the MRD staff (Staff). Dr. Cornell did not appear and the hearing proceeded on a default basis.

Notice and jurisdiction were established and will be addressed in the findings of fact and conclusions of law. The hearing notice and the MRD official were admitted into evidence. The discussion and decision below are based on this evidence.

II. DISCUSSION

A. Background

Claimant sustained a compensable worker’s compensation injury on________. Provider Linda Cordell, M.D., rendered various pain management medical services to the claimant and requested reimbursement from Petitioner. Provider sought reimbursement under CPT Code 97799-CP at a rate of $150.00 per hour of treatment, and Petitioner paid at the rate of $100.00 per hour. Provider also sought reimbursement under CPT Code 99361 a team conference and Petitioner denied the reimbursement.

B. Liberty Mutual Evidence and Argument

Liberty Mutual offered evidence establishing that the average regional charges for the services provided under CPT 97799 for chronic pain management were $100.00 per hour. This evidence and the analysis of the procedures by Liberty Mutual also took into consideration the relative value and fee schedule allowable of the individual components of the services provided. Liberty Mutual evaluated the services in comparison to the reasonable rate for inpatient treatment as well. Provider did not appear, and thus, provided no documentation supporting the rate of $150.00 per hour.

Provider also sought reimbursement for a separate charge under code 99361, but the guidelines provide that this should be included as global in the doctor’s overall duties.

C. Issues Presented and ALJ Analysis

The ALJ concludes that documents submitted by Petitioner support Petitioner’s position. The analysis of the procedures set out in the documents offer a reasonable explanation for payment of $100. 00 hour and is the only evidence that can be considered by the ALJ. Therefore, the ALJ finds that Petitioner has met its burden of proof and Provider is not entitled to additional reimbursement.

III. FINDINGS OF FACT

  1. On_______, Claimant sustained a compensable workers’ compensation injury.
  2. On February 13, 14, 15, and 16, 2001, Dr. Linda Cordell treated Claimant for chronic pain.
  3. Dr. Cordell submitted a claim for $4,253.00 to Liberty Mutual Fire Insurance Company for Claimant’s treatment on the dates described in Finding Fact No. 2.
  4. Liberty Mutual paid $2,600.00 to Dr. Cordell for Claimant’s treatment on the dates described in Finding Fact No. 2.
  5. Dr. Cordell requested medical dispute resolution from the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) on ________ claim.
  6. On September 5, 2001, MRD issued its decision ordering Liberty Mutual to remit an additional $813.00, plus accrued interest to Dr. Cordell for ______ treatment.
  7. On September 14, 2001, Liberty Mutual filed a request for a hearing on the MRD decision regarding ________ treatment.
  8. On October 15, 2001, TWCC sent notice to the parties of the hearing for the _______matter scheduled for September 10, 2002, at 9:00 a.m., and a Statement of Matters Asserted on August 30, 2002. The hearing notice and the statement of matters asserted informed the parties of the matter to be determined, the right to appear and be represented by counsel, the time and place of the hearing, and the statutes and rules involved.
  9. On September 9, 2002, ALJ John H. Beeler convened the hearing on the merits in this matter. Shannon Butterworth appeared on behalf of Liberty Mutual. Dr. Cordell did not appear and was not represented by counsel. TWCC did not appear. The record closed on September 24, 2002.
  10. Liberty Mutual correctly paid Dr. Cordell for treating Claimant.
  11. Dr. Cordell is not entitled to additional payment from Liberty Mutual for her treatment of Claimant.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issues presented, pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031 (Vernon Supp. 2000).
  2. The State Office of Administrative Hearings has jurisdiction over matters relating to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to §§ 402.073 and 413.031(d) of the Act and Tex.Gov’t Code Ann. ch. 2003 (Vernon 2000).
  3. Liberty Mutual timely filed requests for hearing, as specified in 28 Tex.. Admin. Code (TAC) §148.3 in both instances.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Govt. Code Ann. ch. 2001 (Vernon 2000) and 28 TAC § 148.4(b).
  5. Liberty Mutual had the burden of proving the cases by a preponderance of the evidence, pursuant to 28 TAC § 148.21 (h) and (i).
  6. Based on the above Findings of Fact Liberty Mutual showed that the amount paid to Dr. Cordell for treatment of ___________ was proper.
  7. Based on the foregoing findings of fact and conclusions of law, Liberty Mutual met its burden of proof to show it should not be required to reimburse Dr. Cordell additional funds for her treatment of________.

ORDER

It is hereby ordered thatthe MRD’s Decision in SOAH Docket No.453-02-0395.M4, ordering Liberty Mutual Fire Insurance Company to remit $813.00, plus all accrued interest due at the time of payment toLinda Cordell, M.D., is hereby reversed as provided by Tex. Lab. Code Ann. §413.016(b). No reimbursement is due.

This decision is final on the date when the party is notified of the decision according to 28 TEX. ADMIN. CODE § 148.22(H). If the decision was mailed, a party or the party’s representative is presumed to have been notified on the date on which the notice was sent.

Signed on the 19th day of November, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JOHN H. BEELER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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