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At a Glance:
Title:
453-02-1315-m5
Date:
July 24, 2002

453-02-1315-m5

July 24, 2002

DECISION AND ORDER

Petitioner, EZ Rx Pharmacies, seeks reimbursement for the prescription medications Vicoprofen, Vanadom, and MS Cortin, which were provided to an injured worker. Although the Medical Review Division of the Texas Workers’ Compensation Commission (MRD) ordered the insurance carrier, Facility Insurance Company (Respondent), to reimburse Petitioner, Petitioner contends MRD incorrectly calculated the amount due. This decision agrees with Petitioner that it is entitled to the total amount it billed, $966.06.

I. Procedural History

Both parties appeared at the hearing, which convened and closed on June 4, 2002, before Administrative Law Judge Gary W. Elkins. As reflected in the Findings and Conclusions, jurisdiction was established and adequate notice was provided.

II. Statement of The Case

Petitioner billed Respondent $966.06 for the prescription medications Vicoprofen, Vanadom, and MS Cortin provided to an injured worker. Respondent refused reimbursement on the basis that the drugs were prescribed without the treating doctor’s approval. Petitioner then sought medical dispute resolution before MRD, which ordered reimbursement of $278.03. Petitioner agreed with MRD’s conclusion that reimbursement was due but disagreed with the amount of reimbursement ordered. Consequently, it requested a hearing before the State Office of Administrative Hearings.

Based on the evidence, this decision agrees that MRD incorrectly calculated the amount to be reimbursed. Instead, consistent with the formula for reimbursement contained in the Commission’s Medical Fee Guideline, Petitioner is entitled to total reimbursement of $966.06.

III. Findings of Fact

  1. Petitioner, EZ Rx Pharmacies, billed Respondent, Facility Insurance Company, $966.06 for the prescription medications Vicoprofen, Vanadom, and MS Contin it provided to an injured worker.
  2. Respondent refused reimbursement on the basis that the drugs were prescribed without the treating doctor’s approval.
  3. Based on the refused reimbursement, Petitioner sought medical dispute resolution before MRD, which ordered reimbursement of $278.03.
  4. Petitioner agreed with MRD’s conclusion that reimbursement was due but disagreed with the amount of reimbursement ordered by MRD. Consequently, it requested a hearing before the State Office of Administrative Hearings.
  5. Notice of the hearing was sent to the parties on January 11, 2002.
  6. 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.
  7. The hearing convened and closed June 4, 2002, with Administrative Law Judge (ALJ) Gary W. Elkins presiding. Both Petitioner and Respondent appeared. The Texas Workers’ Compensation Commission was not a party.
  8. On July 26, 2000, Petitioner dispensed 180 Vicoprofen, 194 Vanadom, and 62 MS Contin pills to the injured worker.
  9. MRD used the wrong quantity of pills when calculating the amount of reimbursement due Petitioner.
  10. Based on the correct number of pills dispensed to the injured worker, Petitioner properly billed $966.06 for the prescribed drugs.

IV. 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. Petitioner timely requested a hearing in accordance with 28 Tex. Admin. Code (TAC) § 148.3.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  5. Petitioner has the burden of proof in this matter. 28 TAC §148.21(h).
  6. Petitioner proved that it billed for the dispensed drugs in accordance with the Commission’s Medical Fee Guideline.
  7. Petitioner met its burden of proof.
  8. Petitioner’s request for reimbursement should be granted.

ORDER

IT IS ORDERED that Facility Insurance Company reimburse EZ Rx Pharmacies a total of $966.06 for Vicoprofen, Vanadom, and MS Contin dispensed to an injured worker on July 26, 2000.

Signed this 24th day of July, 2002.

Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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