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At a Glance:
Title:
453-02-1297-m5
Date:
June 27, 2002
Status:
Retrospective Medical Necessity

453-02-1297-m5

June 27, 2002

DECISION AND ORDER

I. SUMMARY

Adom Rehabilitation and Physical Medicine (Adom Rehabilitation or Provider) sought reimbursement for work hardening services provided Claimant___, but Ft. Bend Independent School District (the Carrier) denied payment. Subsequently, the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) denied the claim. The Provider requested a hearing to challenge the MRD’s order.

On June 4, 2002, Ruth Casarez, Administrative Law Judge (ALJ), convened the hearing at the William P. Clements Building, 300 West 15th Street, Austin, Texas. Attorney Mark Sickles represented the Carrier. Diane Hodge, an employee of Adom Rehabilitation, represented the Provider. The Commission was not represented. The parties did not contest notice or jurisdiction. After evidence was presented, the ALJ closed the hearing on June 4, 2002.

II. EVIDENCE AND DISCUSSION

Ms. Hodge testified very briefly and introduced into evidence a copy of the MRD’s certified record (C.R.) and a copy of daily notes prepared on Claimant’s progress during the work hardening program.[1] The Carrier presented a packet of explanations of benefits (EOBs) that had been sent to Provider by CorVel or Ward North America[2] in January 2001. The issue in this case is whether the Provider documented the services provided Claimant between June 12, 2000, and July 14, 2000, in accordance with the work hardening provisions of the Medical Fee Guideline (MFG) Medicine Ground Rules. If it did, it would be entitled to reimbursement of its $6,656 claim.

The Provider’s documentation indicated Claimant suffered a job-related injury on _____, but it did not include a description of the injury or of the severity of the injury. Likewise, no indication was given as to Claimant’s job at the time of her injury or as to how she was injured.

Work hardening is an individualized, highly structured, goal-oriented treatment program designed to maximize the ability of the person receiving the treatment to return to work. Work hardening programs are interdisciplinary, intended to address the functional, physical, behavioral, and vocational needs of the Claimant. The Commission has adopted rules governing work hardening programs. The MFG rules relate to, among other things, when work hardening is appropriate, how such programs are to be administered and billed, and what documentation is required of work hardening providers.[3]

The MRD Officer found the Provider did not document all daily activities performed by Claimant, including the duration of the activities, as required by the work hardening rules. Nor did the Provider document the total time the Claimant spent in the program each day, so as to support the time billed. The MRD Officer therefore denied payment of the claim.

Ms. Hodge argued the weekly progress reports in the certified record reflected (a) the goals of the work hardening program, (b) Claimant’s functional status, (c) the activities Claimant performed, and (d) any complications that existed. She argued the Provider should get paid because the reports showed Claimant had made progress during the program.

Having reviewed the Provider’s documentation, the ALJ finds it quite limited, with no description of the event that lead to the injury, what part of the Claimant’s body was injured, or what job Claimant performed at the time of her injury. In addition, there are no functional capacity evaluation reports that indicate Claimant’s condition or physical demand level (PDL) prior to the work hardening or her progress during and after the program. The ALJ infers Claimant injured her back, but the reports in the record provide no details whatsoever as to how she injured it or how severe the injury was. Indeed, most of Provider’s records are very general and give little or inaccurate information. For example, the one-page weekly report for the weeks of June 12 (the first week of work hardening) and June16 states the following:

Main job-related goal: tolerate an 8-hour work week (sic).

Previous short term goal: Have completed 4 weeks of work hardening program. (Emphasis added)

During this week she has improved strength, range of motion, endurance

and job specified activities.

Important activities:

06/09/00

06/16/00

Floor to waist lift

15#/20 min

20#/25 min

Floor to shoulder

15#/20 min

20#/25 min

Pivot to waist

15#/20 min

20#/25 min

Box carry

15#/20 min

20#/25 min

One hand carry

15#/20 min

20#/25 min

Treadmill

20 min

25 min

Circuit training

15 Reps

20 Reps

Leg Press

15 Bilat/15 Reps

20 Bilat/20 Reps

Push/pull

15#/20 min

20#/25 min

Stocking overhead

15#/20 min

20#/25 min

Other Activities: [Claimant] has participated in group session and educational courses.

Functional Status/Symptoms: [Claimant] has accomplished the activities indicated above. She participated in activities to improve strength, range of motion, endurance and job specified.

Complications/Contributing Circumstances: [Claimant] is doing very well. Feels a lot better than she did last week.[4]

Four such reports were submitted to the MRD with the request for dispute resolution. The main differences in each report were reflected in the number and length of time of the activities listed above, e.g., on 6/23/00, the number of pounds involved in the first five activities increased to 25, and the five exercises lasted 30 minutes each.

The Provider did not submit its daily progress notes to the MRD prior to the issuance of the MRD decision, but introduced them at the hearing.[5] However, like the weekly reports, the daily notes also fail to indicate how long the Claimant participated in the work hardening program each day. They also contain few, if any, details about Claimant’s response to the specific work hardening activities that she performed. There is nothing to show if Claimant’s functional level of performance or her PDL rating changed at all as a result of the exercises and activities she performed in the program. The notes include general statements, such as Claimant states that “her stomach problems has (sic) significantly decreased,”[6] “lumbar rotation is increasing, and balance is steady.” And whil

the notes do reflect Claimant participated in the listed activities for specified periods of time, they do not specify the total number of hours, which would include the length of time in group or educational sessions, that Claimant spent in the program each day.

Furthermore, the ALJ cannot determine if the activities were appropriate, because the Provider did not describe Claimant’s injury or the job that it was preparing her to perform. Nor can the ALJ determine if the group sessions or classes were relevant to Claimant’s condition, because the Provider did not indicate what the sessions were about nor who conducted them. Additionally, the records include no comprehensive treatment plan that set out (a) specific goals for Claimant, (b) Claimant’s job duties and the job simulation activities that she would perform during the program; (c) Claimant’s condition at the start of the program; and (d) the improvement that was projected at the end of the program that would allow Claimant to return to work. Similarly, no functional capacity evaluation (FCE) reports (including a final FCE report) were provided which detailed what progress, if any, Claimant had made during the program or whether Claimant was fit to return to her job at the end of the program. In short, Provider’s documentation lacked important information about Claimant’s functional status before, during, and after the work hardening program and does not comport with MFG Medicine Ground Rule II.E.

The MRD Officer found the documentation supplied by Provider did not meet the requirements of the work hardening rules set out in MFG Medicine Ground Rule II. E. The ALJ reaches the same conclusion after reviewing the certified record and the additional daily progress notes that were presented. The Provider did not prove it was entitled to reimbursement. The facts and reasoning in support of this decision are set forth in the findings of fact. The legal conclusions derived from those facts appear in the conclusions of law.

III. FINDINGS OF FACT

  1. Claimant, an employee of the Ft. Bend Independent School District, sustained a work-related injury on_________.
  2. At the time of the injury, Claimant’s employer, Ft. Bend Independent School District (the Carrier), was a self insurer.
  3. Warren B. Dailey, the treating doctor, referred Claimant to Provider’s work hardening program.
  4. The primary goal of a work hardening program, which is interdisciplinary in nature, is to prepare an individual, physically and otherwise, to return to work.
  5. Adom Rehabilitation and Physical Medicine (the Provider) furnished what it classified as work hardening services to Claimant between June 12, 2000, and July 14, 2000.
  6. No definitive evidence was presented concerning the type, nature, or severity of the injury that Claimant suffered or as to the particular parts or areas of the body that were injured.
  7. No evidence was presented that a functional capacity evaluation (FCE) was conducted to determine if Claimant was an appropriate candidate for work hardening.
  8. No evidence was presented as to Claimant’s physical demand level (PDL) rating at the time she enrolled in Provider’s work hardening program, nor of the PDL required of the job for which she would be prepared in the work hardening program.
  9. No evidence was presented as to the type of job or duties that Claimant would be required to perform on the job after she completed the work hardening program.
  10. No evidence was presented as to the specific health care professional(s) who worked with Claimant during the program, or as to the type of sessions or courses that Claimant received during the program.
  11. No evidence was presented that Provider prepared an individualized treatment plan that established specific goals that were set for Claimant to achieve in the work hardening program, or specific job simulation activities or exercises that Claimant would have to complete to meet the program goals.
  12. No evidence was presented that detailed the number of hours per day that Claimant participated in the work hardening program, or that included the following: (a) Claimant’s daily progress after performing specific tasks; (b) the specific job-simulation tasks that Claimant performed and what progress, if any, was made; or (c) what, if any, changes needed to be made in the treatment plan, considering Claimant’s progress or lack thereof.
  13. No evidence was presented that an initial, interim, or discharge FCE was conducted to assess
  14. the need for work hardening, Claimant’s interim progress during the program, or whether changes were required in the treatment plan, considering Claimant’s response to the program.
  15. Provider’s daily notes indicated that Claimant did not participate in the work hardening program on five days during the four and a half-week program, without indicating an explanation for each missed appointment.
  16. The Provider submitted claims to the Carrier in the amount of $6,656 for the services it rendered to Claimant.
  17. The Carrier denied reimbursement of the claim.
  18. On July 5, 2001, the Provider appealed the Carrier’s denial to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission).
  19. On November 5, 2001, the MRD concluded that Provider’s documentation did not substantiate the daily treatment or patient response to the treatment, nor did it support the time billed for the services, and issued its decision denying the Provider’s claim of $6,656.
  20. On November 14, 2001, the Provider filed a request for a hearing regarding the disputed reimbursement.
  21. The Commission sent notice of the hearing to the parties on January 10, 2002. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  22. The hearing was held on June 4, 2002. The Provider was represented by its employee, Ms. Hodge, and the Carrier was represented by its attorney, Mark Sickles. The record closed on the same day.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 413.031.
  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. Lab. Code Ann. §§ 402.073 and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. The Provider timely filed notice of appeal of the MRD decision, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code Ann. ch. 2001 and 28 TAC §148.4(b).
  5. The Provider had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC § 148.21(h) and (i).
  6. The Provider failed to prove that the services rendered Claimant met the requirements set out in the Medical Fee Guideline (MFG) Medicine Ground Rule II. E. 3, 6, and 7.
  7. The Provider failed to meet the documentation requirements of MFG Medicine Ground Rule II. E. 8 - 10.
  8. Based on the foregoing findings of fact and conclusions of law, the Provider did not prove that its claim for $6,656 should be reimbursed.

ORDER

It is hereby ordered that Adom Rehabilitation and Physical Medicine’s claim is denied.

Signed this 27thday of June, 2002.

RUTH CASAREZ
Administrative Law Judge
State Office of Administrative Hearing

  1. Ms. Hodge indicated the daily notes had been sent to the MRD and the Carrier after the MRD review.
  2. Mr. Sickles explained that the school district’s insurance administrator had changed over the years from Ward North America to Berkley Risk Administrators in Lubbock. At one time, CorVel also administered the district’s claims.
  3. See Medical Fee Guideline Medicine Ground Rule II. E. and 28 Tex. Admin. Code§ 134.201.
  4. See C.R. p. 12.
  5. See Petitioner’s Ex. 2 for copies of Provider’s daily progress notes.
  6. No indication was given whether Claimant’s stomach problems were in any way related to her injury.
End of Document
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