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At a Glance:
March 13, 2020


March 13, 2020


I. Background and Procedural History

The Clinic for Special Surgery (the Clinic or Petitioner) is an ambulatory surgical center (ASC). Patient ____ was treated at the Clinic with an epidural steroid injection. The Clinic submitted a bill for $2,840.48 to Hartford Fire Insurance (Hartford) for services rendered to___ Hartford paid the Clinic $2,236.00. The Clinic requested dispute resolution. The Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission) declined to order additional payment, and the Petitioner appealed the decision.

The rate of reimbursement for ASCs is in dispute because the Commission does not currently have a guideline mandating a fixed amount for ASC charges for outpatient procedures. The services are to be reimbursed at a fair and reasonable rate.

The Administrative Law Judge (ALJ) convened a hearing on January 28, 2002. No party appeared. The ALJ took judicial notice of the notice to the Petitioner (Ex. 1) and the certified record (Ex. 2). Based on the evidence, the ALJ finds that Petitioner failed to carry its burden of proving it is entitled to additional reimbursement.

II. Findings of Fact

  1. On_________, ____ suffered a compensable injury and was employed at the time by an employer carrying workers’ compensation insurance underwritten by Hartford.
  2. On May 24, 2000, Daniel K. Boatright, D.O., used the Clinic’s facilities to treat____ with a fluoroscopically-guided epidural steroid injection.
  3. The Clinic requested reimbursement of $2,840.48, its usual and customary fee, from Hartford.
  4. Hartford paid the Clinic $2,236.00 for the services, as being fair and reasonable payment.
  5. The Clinic sought additional reimbursement of $604.48 and submitted a request for dispute-resolution on April 23, 2001. The MRD issued its Findings and Decision on October 24, 2001, denying additional reimbursement.
  6. The Clinic requested a hearing on October 31, 2001, and the Commission issued its Notice of Hearing on November 27, 2001.
  7. Administrative Law Judge Katherine Smith convened the hearing on the disputed hearing January 28, 2002, and the record closed the same day. No party appeared or requested an appearance by telephone.
  8. The Clinic provided explanation of benefits or reimbursement (EOBs) from other carriers showing that other carriers have been willing to reimburse 100% of the Clinic’s usual and customary charges for the same and similar services provided by the Clinic.
  9. Showing what other carriers have been willing to pay is not evidence of effective medical cost control and is not evidence of amounts paid on behalf of managed care patients of ASCs or on behalf of other non-workers’ compensation patients with an equivalent standard of living.
  10. The EOBs provided by the Clinic do not support additional reimbursement.

III. Conclusions of Law

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act. Tex. Labor Code Ann. § 413.031 (Vernon 1996).
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. § 413.031(d) and Tex. Gov’t Code Ann., ch. 2003 (Vernon 2000).
  3. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann.§§ 2001.051 & 2001.052 (Vernon 2000).
  4. Workers’ compensation insurance covers all medically necessary health care, which includes all reasonable medical aid, examinations, treatments, diagnoses, evaluations, and services reasonably required by the nature of the compensable injury, and reasonably intended to cure or relieve the effects naturally resulting from a compensable injury. It includes procedures designed to promote recovery or to enhance the injured worker's ability to get or keep employment. Tex.Lab. Code Ann. § 401.011(19) and (31).
  5. The Clinic had the burden of proving by a preponderance of the evidence that it was entitled to additional reimbursement. 28 Tex. Admin. Code (TAC) § 148.21(h).
  6. The Commission rules provide, “Reimbursement for services not identified in an established fee guideline shall be reimbursed at fair and reasonable rates as described in the Texas Workers’ Compensation Act, Section 8.21(b), until such time that specific guidelines are established by the commission.” (Emphasis added.) 28 TAC § 134.1(f). (Section 8.21(b) is now codified as § 413.011(b) of the Texas Labor Code.).
  7. Section 413.011 of the Guidelines and Medical Policies of the Texas Labor Code provides that:
    1. 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. The commission shall consider the increased security of payment afforded by this subtitle in establishing the fee guidelines. (Emphasis added.)
    2. A “usual and customary” charge may be the same as a “fair and reasonable” one only if there is evidence that the factors set out in § 413.011 of the Texas Labor Code are also met; that is, that the charge achieves effective medical cost control, takes into account payments made to others with an equivalent standard of living, and considers the increased security of payment.28 TAC § 133.(8).
    3. Based on Findings of Fact Nos. 8-10 and Conclusions of Law Nos. 6-8, the Clinic failed to meet its burden of proof that its charges are fair and reasonable. Tex. Labor Code Ann. § 413.011(b).


IT IS, THEREFORE, ORDERED that the appeal of the Clinic for Special Surgery Center requesting additional reimbursement for the services provided is DENIED.

Signed this 13th day of March, 2020.



Administrative Law Judge
State Office of Administrative Hearings

End of Document