DECISION AND ORDER
I. PROCEDURAL HISTORY
Travelers Indemnity Company of Connecticut (Travelers or Carrier) challenges the reimbursement to Rehab 2112 (Provider) for physical therapy sessions administered to workers’ compensation Claimant_____ on August 6, 10, 17, and September 4, 2001. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) granted reimbursement for the four charges in question. The Carrier challenges the MRD’s decision to reimburse.
The Administrative Law Judge (ALJ) convened the hearing on September 9, 2002. The presentation of evidence was concluded on that date, but the record was left open until September 16, 2002, to allow the parties to continue settlement talks. Dan Flanagan, an employee of Travelers, represented the Carrier. Attorney Doug Pruett represented the Provider.
II. EVIDENCE AND BASIS FOR DECISION
The issue in this case is whether the physical therapy sessions on the dates in question were preauthorized, and if so, whether Carrier should be required to pay for them.
The evidence presented consisted of the 65-page certified record (C.R.) of the MRD proceeding. Mr. Flanagan argued that the Carrier had already paid for the services rendered in August, but not for the treatment on September 4, 2001, because it did not believe that date of service d been preauthorized. The Provider identified the preauthorization letters (C.R. pp. 20 & 39) for the four dates in question, and argued that all four dates of service had, in fact, been preauthorized and should be paid. Furthermore, although the Carrier stated it had paid for some of the services, it presented no evidence of such payments. Thus, the Provider urged that an order for payment of all four dates of services plus interest should be entered.
Based on the evidence received, the ALJ concludes the Carrier failed to prove that the services had not been preauthorized and should not be paid. The particular facts, reasoning, and legal analysis in support of the decision are set out below in the Findings of Fact and Conclusions of Law.
III. FINDINGS OF FACT
- On______, Claimant _____ an account representative with_____, suffered a compensable injury to her right knee when she tripped and fell over a buckle in the carpet.
- ______had workers’ compensation coverage with the Travelers Indemnity Company of Connecticut (Travelers or Carrier) at the time of Claimant’s injury.
- Claimant received surgery on her right knee on May 16, 2001.
- Treating physician Mark Rayshell, D.C., of Rehab 2112 (Provider), administered active physical therapy to Claimant from June 11, 2001, through July 13, 2001. In mid-July, Provider requested preauthorization for additional physical therapy treatments.
- On July 18, 2001, Travelers gave preauthorization for additional physical therapy from July 17, 2001, through August 17, 2001, (three times per week for four weeks).
- Although Claimant made some progress with the additional treatment, she continued to have functional muscle weakness and endurance problems.
- On August 20, 2001, Dr. Rayshell recommended four additional weeks of post-operation physical therapy. Provider sought preauthorization for such therapy.
- On August 27, 2001, Travelers preauthorized one additional week of active physical therapy, three times per week for one week. While Travelers’ letter does not specifically state the date on which the therapy would begin, a reasonable interpretation is that the treatment was authorized to begin on the following day, August 28, 2001, and go until September 4, 2001.
- The Provider rendered active physical therapy to Claimant on the dates in question (August 6, 10, 17, and September 4, 2001).
- The Provider submitted its charges to the Carrier for the active physical therapy administered to Claimant between August 6, 2001 and September 4, 2001.
- The Carrier denied payment of $315 under denial code A, “Preauthorization required but not requested,” claiming that preauthorization was not obtained for the four dates in question
- On December 5, 2001, the Provider requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) seeking reimbursement of $315 for the active physical therapy administered to Claimant on the four dates at issue.
- On February 12, 2002, the MRD issued a decision ordering the Carrier to remit $315 plus all accrued interest because the Provider had obtained preauthorization for the services.
- On February 21, 2002, the Carrier appealed the MRD’s decision
- The Commission sent a notice of hearing to the parties on March 25, 2002. The notice contained a statement of the time and place of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
- A hearing was held on September 9, 2002. Travelers’ employee Dan Flanagan represented the Carrier. Attorney Doug Pruett represented the Provider. The record of the hearing closed on September 16, 2002.
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
- 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§ 413.031(d) of the Act; Tex. Gov't Code Ann. ch. 2003, and 28 Tex. Admin. Code (TAC) chs. 148 and 149.
- The Carrier timely appealed the MRD’s decision, pursuant to 28 TAC § 148.3.
- The notice of hearing sent by the Commission complied with the requirements of Tex. Gov’t Code § 2001.052 and of 28 TAC §148.4(b).
- Pursuant to § 413.031 of the Act and 28 TAC § 148.21(h) and (i), the Carrier had the burden of proof to show by a preponderance of the evidence that it should not be required to pay for the medical services rendered by Provider on the dates in question.
- Section 408.021 of the Act and 28 TAC § 134.600(a)(1), provide that a carrier is liable for the necessary medical costs and treatments where the health care provider received preauthorization to render the services from the carrier as required by 28 TAC § 134.600(h).
- The Carrier preauthorized additional physical therapy treatments three times per week for four weeks from July 17, 2001 to August 17, 2001. Services rendered by Provider on August 6, 10, and 17, 2001, fall within this preauthorization.
- On August 27, 2001, the Carrier preauthorized an additional week of physical therapy treatment to begin on August 28, through September 4, 2001. The physical therapy provided on September 4, 2001, falls within the Carrier’s final preauthorization.
It is hereby ordered that Travelers Indemnity Company of Connecticut reimburse Rehab 2112 $315 plus interest for the physical therapy preauthorized by the Carrier and administered to Claimant on August 6, 10, 17, and September 4, 2001.
Signed this 25th day of October 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- At the end of the evidentiary hearing, the parties indicated there was a possibility the dispute could be settled within a few days. The ALJ left the record open for one week and asked the parties to send evidence of their agreement, if they settled. As of September 16, 2002, the parties had submitted nothing to indicate the case had settled.↑