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At a Glance:
Title:
453-02-2726-m5
Date:
May 30, 2002
Status:
Retrospective Medical Necessity

453-02-2726-m5

May 30, 2002

DECISION AND ORDER

John A. Sazy, M.D. (Provider) appealed the Findings and Decision issued by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) which ordered it to pay $ 132.50 to Travelers Indemnity Company of Connecticut as a refund for over-payment by Travelers Indemnity Company of Connecticut (Carrier).

This decision finds that Petitioner met its burden of proof that it should not have to pay the refund to the Carrier but instead, is owed the additional amount of $ 1,385.00 from Carrier.

I.PROCEDURAL HISTORY, JURISDICTION, AND NOTICE

On May 28, 2002, ALJ Suzanne Marshall convened the hearing at the William C. Clements Building in Austin, Texas. Kaly Sazy, office manager for Dr. John A. Sazy, appeared on Dr. Sazy’s behalf. Attorney Dan Flannagan represented Travelers Indemnity Company of Connecticut. Counsel for the Commission had previously notified the parties that it would not participate in the hearing.

Notice and jurisdiction were not contested and will be addressed in the findings of fact and conclusions of law. The facts in this case are also not in dispute and are set forth in the Findings of Fact below.

II. FINDINGS OF FACT

  1. On November 14, 2001, the Commissions’ Medical Review Division (MRD) issued its Findings and Decision which recommended that the Provider reimburse Carrier the amount of $ 132.50, which represented the amount of an over-payment by the Carrier to Provider.
  2. On November 29, 2001, Provider requested an appeal of the MRD decision.
  3. The Commission sent notice of the hearing to the parties on April 24, 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.
  4. The Commission did not file a Statement of Matters Asserted in this case.
  5. The Commission prepared a recalculation of the amounts in issue and concluded that the MRD decision was in error and that Carrier owed an additional $ 1,385.00 to Provider.
  6. Carrier did not contest the recalculated amounts and agreed that Provider was entitled to additional reimbursement of $ 1,385.00.

III. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue 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 related 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. Provider timely filed a request for hearing, 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 (Vernon 2000) and 28 TAC §148.4(b).
  5. Provider had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC §148.21(h) and (i).
  6. Based on Findings of Fact No. 5, Provider met his burden of proving that it should not have to pay $ 132.50 as a refund to Carrier.
  7. Based on Findings of Fact Nos. 5 and 6, Provider proved that he was entitled to additional reimbursement from Carrier in the amount of $ 1,385.00.

ORDER

It is hereby ordered that Travelers Indemnity Company of Connecticut pay John A. Sazy, M.D. the amount of $ 1,385.00.

Signed this 30th day of May, 2002.

SUZANNE FORMBY MARSHALL
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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