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At a Glance:
Title:
453-02-3490-m5
Date:
November 18, 2002
Status:
Retrospective Medical Necessity

453-02-3490-m5

November 18, 2002

DECISIONAND ORDER

The issue in this case, which is before the Administrative Law Judge (ALJ) on a motion for summary disposition, is whether the cost of copying records to be provided to a designated doctor selected by the Texas Workers’ Compensation Commission (TWCC or the Commission) are compensable. The amount in controversy is $104.50.

The ALJ determines that copying costs incurred in providing medical records to a designated doctor are reimbursable under the Commission’s rules, and therefore orders that Petitioner Transcontinental Insurance Company[1] (Carrier) pay for the copying costs at issue in this case.

I. Jurisdiction, Notice, and Procedural History

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. Tex. Lab. Code Ann. §413.031; Tex. Gov’t Code Ann. ch. 2003.

The Commission’s Medical Review Division (MRD) issued its decision May 15, 2002. Carrier requested a hearing. Proper and timely notice of the hearing was issued July 9, 2002, setting the hearing on the merits for September 23, 2002.

Prior to the hearing on the merits, Carrier filed a Motion for Summary Disposition and requested that the hearing on September 23 be converted to a pre-hearing conference concerning the Motion for Summary Disposition. This request concerning the hearing was granted. Respondent Jesus Garcia, D.C., did not appear at the pre-hearing conference on September 23. The conference proceeded in his absence.

At the pre-hearing conference, the certified record from the Texas Workers’ Compensation Commission was admitted in evidence. The ALJ determined that the scope of this appeal is limited to the question of reimbursement for copying costs incurred on November 17, 2000; the claims for these copying costs are the only ones on which the MRD found in Dr. Garcia’s favor, and only Carrier requested a SOAH hearing. The question whether these copying costs are reimbursable is a purely legal issue, and the ALJ heard argument from Carrier in support of its Motion for Summary Disposition.

On September 25, the ALJ issued an order giving Dr. Garcia an opportunity to file a motion setting forth his reasons for not appearing on September 23 and offering legal argument on the question whether costs incurred by a provider in copying medical records to be sent to a designated doctor are to be paid for by the carrier. Dr. Garcia did not submit any such motion. The ALJ therefore rules on Carrier’s Motion for Summary Disposition based on the record and argument presented at the pre-hearing conference, and on the applicable law. And since the ALJ has determined that the only issue in this case is the legal one presented by Carrier’s Motion for Summary Disposition, denial of Carrier’s motion necessitates an order in favor of Dr. Garcia in this case.

II. Undisputed Facts

On November 17, 2000, Dr. Garcia’s office prepared copies of medical files for a designated doctor. Dr. Garcia billed $72.50 under CPT Code 99080 for copies of medical records and $32.00 under CPT Code 99070 for copies of X-rays. TWCC Exhibit 1, p. 73. The Carrier denied these claims. Id., p. 59. The MRD ordered Carrier to pay both amounts, citing to the Commission’s rules 130.6(h) and 133.106. These rules are found at 28 Texas Administrative Code §§130.6(h), 133.106, although the version of § 130.6(h) that was in effect at the time in question in this case is different than the current version.

III. Carrier’s Motion for Summary Disposition

Carrier’s Motion for Summary Disposition asserts that the Commission’s rules do not address who must pay for the costs of records provided to designated doctors. The motion notes that the version of § 130.6(h) in effect in 2000 stated:

The treating doctor and insurance carrier are both responsible for sending to the designated doctor all the employee’s records relating to the medical condition to be evaluated by the designated doctor that are in their possession without a signed release from the employee.

As Carrier states, the rule was silent as to who was to pay for the cost of copying the records. Carrier asserts that the Commission’s rules do provide that insurers pay for copying costs under certain specified circumstances, such as when films and records are needed for a second opinion concerning spinal surgery. See 28 Tex. Admin. Code § 133.206(j)(4). Carrier’s motion goes on to analogize medical records as treatment plans, and notes that the Medical Fee Guideline provides that copies of treatment plans are not reimbursable. See Medical Fee Guideline, p. 31 (1996) (Medicine Ground Rules, I.A.6.).[2] According to Carrier, the rules do not specifically assign to insurers the costs of copying records for designated doctors, and the MRD is wrong to infer such a provision from the language of the rules.

IV. ALJ’s Analysis

The Commission’s rules provide:

The carrier shall reimburse the reasonable copying charge for records provided to designated doctors . . .

28 Tex. Admin. Code § 133.2(c). This rule has been in effect since 1991. By the plain terms of the Commission’s rules, the costs at issue in this case are reimbursable. The MRD’s decision should be affirmed.

V. Ruling on Carrier’s Motion for Summary Disposition

Carrier's Motion for Summary Disposition is denied.

VI. Findings of Fact

  1. The claimant in this case sustained a compensable injury, for which he was treated by Jesus E. Garcia, D.C.
  2. Transcontinental Insurance Company (Carrier) is the workers’ compensation insurer for the claimant’s employer.
  3. On November 17, 2000, Dr. Garcia’s office copied medical records and x-rays to be sent to a designated doctor selected by the Commission.
  4. Dr. Garcia billed $72.50 under CPT Code 99080 for the copies of medical records and $32.00 under CPT Code 99070 for the copies of X-rays. He billed for other services as well.
  5. Carrier denied the claims.
  6. Dr. Garcia sought review from the Commission’s Medical Review Division (MRD).
  7. The MRD issued its decision on May 15, 2002, ordering Carrier to pay $104.50 for the copying costs. The MRD concluded that Carrier did not have to reimburse the other billed amounts.
  8. Carrier requested a hearing before the State Office of Administrative Hearings (SOAH) on the MRD’s decision.
  9. Notice of the hearing was issued July 9, 2002, setting the hearing on the merits for September 23, 2002.
  10. 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.
  11. Prior to the hearing on the merits, Carrier filed a Motion for Summary Disposition and requested that the hearing on September 23 be converted to a pre-hearing conference concerning the Motion for Summary Disposition. This request concerning the hearing was granted.
  12. The pre-hearing conference on September 23, 2002, was convened before Administrative Law Judge Shannon Kilgore and was attended by R. Kyle Hensley and Jane Stone on behalf of Carrier. Respondent Jesus Garcia, D.C., did not appear and was not represented by counsel. The conference proceeded in his absence.
  13. On September 25, 2002, the ALJ issued an order giving Dr. Garcia an opportunity to file a motion setting forth his reasons for not appearing on September 23 and offering legal argument on the question whether costs incurred by a provider in copying medical records to be sent to a designated doctor are to be paid for by the carrier. Dr. Garcia did not submit any such motion.
  14. This Decision and Order is based on the record and argument presented at the pre-hearing conference, and on the applicable law.
  15. The pleadings and record show that there is no genuine issue as to any material fact in this case.
  16. The only issue in this case is whether copying costs for records sent to a designated doctor are reimbursable.

VII. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers’ Compensation Act (the Act). See Tex. Lab. Code ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order in this case. Tex. Lab. Code Ann. § 413.031; Tex. Gov’t Code ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with the Texas Administrative Procedure Act. Tex. Gov’t Code § 2001.052.
  4. The scope of this appeal is limited to the question of reimbursement for copying costs incurred on November 17, 2000.
  5. Any ruling on Carrier’s Motion for Summary Disposition disposes of the only issue in this case, and establishes the basis for issuance of a Decision and Order.1 Tex. Admin. Code § 155.57(a).
  6. The Commission’s rules provide that the carrier shall reimburse the reasonable copying charge for records provided to designated doctors. 28 Tex. Admin. Code § 133.2(c). This provision is presently in effect and was in effect at all times relevant to this case.

ORDER

IT IS, THEREFORE, ORDERED that Carrier’ Motion for Summary Disposition is denied. Dr. Garcia is entitled to an order in his favor as a matter of law. Transcontinental Insurance Company shall reimburse Dr. Jesus E. Garcia, D.C., for $104.50 incurred in copying records sent to a designated doctor selected by the Texas Workers’ Compensation Commission.

Signed this 18th of November, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Shannon Kilgore
Administrative Law Judge

  1. The carrier in this case has mistakenly been referred to in previous documents in this case as “Illinois National Insurance Company.”
  2. See 30 Tex. Admin. Code § 134.201(Commission’s rule adopting the Medical Fee Guideline by reference).
End of Document
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