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At a Glance:
Title:
453-02-2777-m4
Date:
July 17, 2002
Status:
Medical Fees

453-02-2777-m4

July 17, 2002

DECISION AND ORDER

Texas Mutual Insurance Company (Carrier) has appealed the Findings and Decision of the Texas Workers' Compensation Commission's Medical Review Division (MRD) requiring Carrier to reimburse Work Ready Rehab (Provider) $125.00 for the psychological screening of ___(Claimant), to determine his readiness for a work hardening program. The Administrative Law Judge (ALJ) concludes Carrier should not reimburse Provider because Provider did not obtain the required pre-authorization for psychological screening.

I. JURISDICTION, NOTICE, AND VENUE

The Texas Workers' Compensation Commission (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. The State Office of Administrative Hearings (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. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov't Code Ann. ch. 2001 and SOAH’s rules, 1 Tex. Admin. Code (TAC) ch.155.

ALJ Sharon Cloninger convened the hearing May 28, 2002, at the SOAH hearings facility in the William Clements Building, Fourth Floor, 300 West 15th Street, Austin, Texas. Attorney Patricia Eads represented Carrier. Provider was represented by its chief financial officer Barbara Franco. The Commission did not participate in the hearing. The hearing adjourned and the record closed that same day.

Neither party challenged notice or jurisdiction, which are addressed in the Findings of Fact and Conclusions of Law.

II. OVERVIEW

Claimant, a 28-year-old truck driver, suffered a compensable injury on_______, when he fell on the job and fractured his right wrist. On ___, Claimant’s treating physician referred him to Provider for two weeks of daily work hardening, but did not refer him for a psychological/mental health assessment. On September 7, 2001, Provider performed psychological testing on Claimant to evaluate his readiness to enter the work hardening program. Provider did not obtain pre-authorization from Carrier for the psychological testing. Claimant’s first day of work hardening was September 10, 2001.

Provider billed Carrier for the psychological evaluation separately from the work hardening, using CPT Code 90830 (psychological testing). Carrier initially denied reimbursement on the grounds that the psychological evaluation was global to work hardening, and should not have been billed separately. Upon Provider’s re-submission of the bill, Carrier denied payment because Provider had not obtained pre-authorization for the psychological testing.

A. Evidence and argument

Carrier offered the notice documents and the certified copy of the MRD record, both of which were admitted, and called one witness. Carrier also provided the ALJ with a Table of Authorities containing relevant law. Provider offered no documentary evidence and called no witnesses.

Carrier’s Case

a. Ronald Charles Nesbitt

Ronald Charles Nesbitt, a dispute analyst under contract with Carrier, said work hardening is multi-disciplinary and does not typically include psychological services, except as part of group therapy. If a psychological evaluation is conducted prior to work hardening to determine a claimant’s readiness for the program, the provider must obtain pre-authorization for the service. If a psychological service is provided during a work hardening session, it is global to work hardening and not separately reimbursable. Mr. Nesbitt noted that in referring Claimant to Provider for work hardening, Claimant’s treating physician did not check the “psychological/mental health assessment” box on the referral form (Petitioner’s Ex. 2, 18).

Provider’s case

Provider’s position is that under the Medicine Ground Rules found in the Commission’s Medical Fee Guideline (MFG), when an initial mental health evaluation is performed to determine an injured worker’s readiness to enter a work hardening program, the evaluation is not a part of the work hardening program and should be billed separately. Provider also argued that pre-authorization is not required when a mental health evaluation is performed in conjunction with work hardening. Also, Provider pointed out that in a ___, conversation with Carrier’s employee Stacey Arceneaux, Provider obtained pre-authorization for two weeks of daily work hardening for Claimant. (Petitioner’s Ex. 2, 17).[1]

III. DISCUSSION

The law applicable to the issue in this case is set out below, and supports the Carrier’s position that pre-authorization is required for psychological screening conducted prior to a claimant’s entry into a work hardening program.

A. Applicable law

Employee’s entitlement to health care

Tex. Lab. Code Ann. §408.021(a) states:

  1. An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that:
    1. cures or relieves the effects naturally resulting from the compensable injury;
    2. promotes recovery; or
    3. enhances the ability of the employee to return to or retain employment.

Burden of proof

Under 28 TAC §148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to §413.031 of the Act. Thus, Carrier must prove that reimbursement for the psychological testing should be denied.

Pre-authorization requirements

Health care treatments and services requiring pre-authorization are listed at 28 TAC §134.600 (h). Under 28 TAC § 134.600(h)(2), psychiatric or psychological therapy or testing requires pre-authorization except as a part of work hardening.[emphasis added]

To further explain the pre-authorization requirement, Section II.E.2.a. of the Medicine Ground Rules states, “An initial [mental health] evaluation to determine the injured worker’s readiness for the [work hardening] program may be performed prior to entrance into the program. This evaluation is not considered to be part of the Work Hardening program and should be billed

separately. [emphasis added in original]. On the other hand, group therapy provided by a qualified mental health care provider is considered to be a part of the work hardening program.”

Pursuant to 28 TAC §134.600(a), a carrier is liable for the reasonable and necessary medical costs relating to the health care treatments and services listed in 28 TAC §134.600 (h), when the carrier has pre-authorized the treatment or services; there is a life-threatening degree of medical emergency, or the Commission has ordered the treatment.

Rule 134.600(d) requires the Provider to notify the Carrier of the recommended treatment or service listed in subsection (h), prior to the date of the proposed treatment or services.

B. Analysis

The issue in this case is whether Carrier must reimburse Provider for psychological testing of Claimant to determine his readiness for work hardening when Provider did not obtain pre-authorization for the service. A reading of 28 TAC §134.600(h)(2), by itself, could appear to mean that the initial evaluation does not require pre-authorization because it states that psychiatric or psychological therapy or testing requires pre-authorization except as a part of work hardening. [emphasis added]. But Medicine Ground Rule II.E.2.a. clarifies that psychological testing to determine a claimant’s readiness for work hardening - the type of testing conducted in this case - is not a part of the work hardening program. Therefore, the exemption from pre-authorization set out in 28 TAC § 134.600(h)(2) does not apply in this case.

Clearly, Carrier’s initial denial of reimbursement, on the grounds that the psychological evaluation is global to work hardening, was incorrect. Medicine Ground Rules Section II.E.2.a. specifically states that while a psychological test may be conducted to determine a claimant’s readiness for work hardening, such an initial test is not part of work hardening, and is to be billed separately. Provider billed separately for the initial psychological evaluation.

However, Carrier’s subsequent denial of reimbursement, on the grounds that Provider had not obtained pre-authorization for the initial psychological testing, was correct. It is undisputed that Provider failed to obtain pre-authorization for the service. Since the evaluation is not part of the work hardening program, it is not exempt from pre-authorization under 28 TAC §134.600(h). Instead, for the psychological testing to be reimbursable, as set out in 28 TAC §134.600(a), it requires either pre-authorization, or an order of the Commission, or performance as the result of a medical emergency. Provider is seeking reimbursement for services that were not pre-authorized by Carrier, or ordered by the Commission, or performed as the result of a medical emergency. Therefore, Provider is not due any reimbursement.

Carrier has met its burden of establishing that the psychological evaluation was not pre-authorized when it should have been, and that reimbursement should be denied.

IV. FINDINGS OF FACT

  1. ___(Claimant) suffered a compensable job-related injury on_______, when he fell and fractured his right wrist.
  2. On ___, Claimant’s treating physician referred him to Work Ready Rehab (Provider) for participation in a work hardening program.
  3. On the treating physician’s referral form, the box labeled “psychological/mental health assessment” was not checked.
  4. On September 7, 2001, Provider conducted a psychological evaluation of Claimant to determine his readiness for the work hardening program.
  5. Provider did not obtain pre-authorization from Texas Mutual Insurance Company (Carrier) prior to conducting the psychological evaluation referenced in Finding of Fact No. 4.
  6. Claimant’s first work hardening session was September 10, 2001.
  7. Provider billed Carrier $125.00 for the psychological evaluation, using CPT Code 90830 (psychological testing).
  8. Carrier denied Provider’s request for reimbursement, indicating that psychological testing is global to the work hardening program.
  9. Provider re-submitted the bill, and Carrier denied the re-submission because the psychological testing had not been pre-authorized.
  10. On December 21, 2001, Provider filed a timely request for medical dispute resolution.
  11. On March 7, 2002, the Texas Workers’ Compensation Commission’s Medical Review Division issued its Findings and Decision requiring Carrier to reimburse Provider $125.00 for the psychological evaluation.
  12. Carrier filed a timely request for hearing on March 22, 2002.
  13. Notice of the hearing was sent to the parties on May 3, 2002.
  14. 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.
  15. The hearing was conducted May 28, 2002, at the hearings facility of the State Office of Administrative Hearings, Austin, Texas.

CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission (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. The State Office of Administrative Hearings (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. Chapter. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov't CodeAnn., Chapter 2001 and SOAH’s rules, 1 Tex. Admin. Code (TAC) Chapter 155.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann.§2001.052.
  5. Psychological evaluations are not global to work hardening and should be billed separately. Medicine Ground Rules II.E.2.a.
  6. For Carrier to be required to reimburse Provider for the initial psychological evaluation, Provider should have obtained pre-authorization for the service, but did not. 28 TAC § 134.600(h)(2).
  7. Carrier’s denial of reimbursement for the initial psychological evaluation was correct.

ORDER

IT IS, THEREFORE, ORDERED that Petitioner, Texas Mutual Insurance Company, is not required to reimburse Respondent, Work Rehab, $125.00 for the initial psychological evaluation of ___, Claimant.

Signed this 17th day of July 2002.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. However, there is no evidence that Provider obtained pre-authorization for the initial psychological assessment at issue in this proceeding.
End of Document
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