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At a Glance:
Title:
453-02-3198-m4
Date:
December 5, 2002
Status:
Medical Fees

453-02-3198-m4

December 5, 2002

DECISION AND ORDER

The Petitioner in this case, Green Oaks Pain Center (Green Oaks), seeks $7200 in reimbursement for eight sessions of a chronic pain management program provided the workers’ compensation claimant (the Claimant). Although 15 sessions had been authorized, the Carrier, American Zurich Insurance Company, denied reimbursement for the last eight sessions because the Claimant had changed treating doctors mid-program, and the new treating doctor had not authorized the program.

The Administrative Law Judge (ALJ) finds the Carrier did inform the Petitioner of the change in treating doctors. Therefore, he denies Green Oaks’ request for additional reimbursement.

I. Discussion

The Claimant sustained a compensable back injury on________ considerable treatment, Scott Neuberger, D.C., recommended the Claimant be placed in a chronic pain management program. When he made the request, Dr. Neuberger was the Claimant’s treating physician. The Carrier preauthorized 15 sessions of the chronic pain management program based on Dr. Neuberger’s recommendation.

The Claimant began the program at Green Oaks January 19, 2001. On January 16, 2001, however, he had completed a Texas Workers’ Compensation Commission (TWCC or the Commission) Request to Change Treating Doctors form, which TWCC received January 18, 2001, and which was processed January 24, 2001. The Carrier received a copy of the form, but witnesses for Green Oaks testified it did not. The Claimant’s new treating doctor, Randall J. Halbert, D.C., did not recommend the chronic pain management program.

The Carrier’s witnesses, Dr. Emilio Cardona and office manager Jeannie Kujawa, testified Green Oaks never received written or oral notice of the change in treating physicians. Stan Braun, a senior workers’ compensation specialist with American Zurich, testified he called Green Oaks January 31, 2001, and told them of the change.

The Carrier paid for eight sessions of the pain management program, through February 5, 2001. It refused to pay for the remaining eight sessions, which were conducted from February 6 through February 22, 2001. The amount billed for each session was $900, so the amount in dispute is $7200.

After unsuccessfully requesting reconsideration, Green Oaks filed a Request for Medical Dispute Resolution with TWCC. The Commission’s Medical Review Division (MRD) denied the request April 24, 2002. Green Oaks then requested a hearing before the State Office of Administrative Hearings (SOAH).

The hearing was held September 25, 2002, before ALJ Henry D. Card. Dr. Cardona and Ms. Kujawa represented Green Oaks; Steven M. Tipton represented the Carrier. The hearing was adjourned the same day.

Under Tex. Lab. Code Ann. §408.021(c), all health care must be approved or recommended by the employee’s treating doctor, except in case of an emergency. The parties agree that the chronic pain management program was not authorized by the Claimant’s new treating doctor. The ALJ agrees with Green Oaks, however, that the §408.021(c) requirement should not be imposed in this situation if Green Oaks can show it was never notified of the change in treating doctors.[1]

The evidence regarding notification is not overwhelmingly in favor of either side. On the one had, it is certainly possible that the Carrier neglected to inform Green Oaks of the change. Certainly Green Oaks was not aware of the problem, because it continued to treat the Claimant. On the other hand, however, Mr. Braun, relying on his computer notes, testified he had called Green Oaks and had spoken with a woman there, although he did not document or remember her name. His notes stated he mentioned both the change in treating doctors and the need for more detailed descriptions of the services performed. Although the notes could have been more thorough, they contained enough information to persuade the ALJ that the conversation between Mr. Braun and Green Oaks took place. It is more likely that someone at Green Oaks forgot to document the conversation than Mr. Braun fabricated his notes.

Because Green Oaks requested the SOAH hearing, it has the burden of proof under 28 Tex. Admin. Code §148.21(h). The ALJ concludes it did not meet that burden and denies its request for additional reimbursement.

II. Findings of Fact

  1. The Claimant sustained a compensable back injury on_________
  2. After considerable treatment, Scott Neuberger, D.C., recommended the Claimant be placed in a chronic pain management program. When he made the request, Dr. Neuberger was the Claimant’s treating physician.
  3. The Carrier preauthorized 15 sessions of the chronic pain management program based on Dr. Neuberger’s recommendation.
  4. The Claimant began the program at Green Oaks January 19, 2001.
  5. On January 16, 2001, the Claimant had completed a Texas Workers’ Compensation Commission (TWCC or the Commission) Request to Change Treating Doctors form, which TWCC received January 18, 2001, and which was processed January 24, 2001.
  6. The Claimant’s new treating doctor, Randall J. Halbert, D.C., did not recommend the chronic pain management program.
  7. The Carrier paid for eight sessions of the pain management program, through February 5, 2001. It refused to pay for the remaining eight sessions, which were conducted from February 6 through February 22, 2001.
  8. The amount billed for each session was $900, so the amount in dispute is $7200.
  9. After unsuccessfully requesting reconsideration, Green Oaks filed a Request for Medical Dispute Resolution with TWCC.
  10. The Commission’s Medical Review Division (MRD) denied the request April 24, 2002.
  11. Green Oaks timely requested a hearing before the State Office of Administrative Hearings (SOAH).
  12. The hearing was held September 25, 2002, before ALJ Henry D. Card, and was adjourned the same day.
  13. On January 31, 2001, the Carrier informed Green Oaks by telephone of the change in treating physicians.

III. 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. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  4. Under Tex. Lab. Code Ann. §408.021(c), all health care must be approved or recommended by the employee’s treating doctor, except in case of an emergency.
  5. Green Oaks has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  6. Green Oaks did not prove it was entitled to additional reimbursement.
  7. Green Oaks’s request for additional reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Green Oaks Pain Center’s request for additional reimbursement of $7200 for services performed for the Claimant between February 6 and February 22, 2001, is denied.

Signed this 5th day of December, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. The Carrier also contended the treatments were not necessary and were inadequately documented. The ALJ does not reach those issues.
End of Document
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