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At a Glance:
Title:
453-03-0898-m4
Date:
February 7, 2003
Status:
Medical Fees

453-03-0898-m4

February 7, 2003

DECISION AND ORDER

Alta Healthcare Clinic, L.P., (Alta) seeks reimbursement for chiropractic services provided to workers’ compensation claimant E.G. in 2001. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC or Commission) found in favor of the carrier, Clarendon National Insurance Company (Clarendon), because of problems with Alta’s documentation. The ALJ finds that the evidence does not support the MRD’s decision, and determines that Alta should be reimbursed $596.00 for the disputed claims 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, pursuant to Tex. Lab. Code Ann. §413.031 and Tex. Gov’t Code Ann. ch. 2003. Clarendon challenges SOAH’s jurisdiction over part of this case, and that issue is addressed in more detail below in the discussion of the issues.

The MRD issued its decision on October 4, 2002. Alta filed a timely request for hearing. Proper and timely notice of the hearing was issued October 31, 2002. The hearing was convened December 11, 2002, with ALJ Shannon Kilgore presiding. Ben Higbee, D.C., appeared for Alta, and Steven M. Tipton appeared for Clarendon. The hearing was adjourned and the record closed the same day.

II. Legal Standards

Section 408.021 of the Texas Labor Code states:

(a)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.

Section 401.11(19) defines “health care” to include “all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations, and medical services.”

The Commission’s rules require both insurers and medical professionals to provide each other with certain documentation during the claims and reimbursement process, and to produce documentation during the medical fee dispute process. See 28Tex. Admin. Code §§ 133.304, 133.305.

Alta, the petitioner, has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).

III. Discussion

Background. The workers’ compensation claimant in this case suffered a wrist injury on_______. The claimant received treatment at Alta on multiple dates from February through November 2001. See TWCC Exhibit 1, pp. 37-41 (Alta’s original request for medical dispute resolution). In February 2002 Alta requested dispute resolution before the MRD in connection with many dates of service in 2001. Alta’s request stated that some claims had been denied for lack of pre-authorization, and some had been denied because the carrier had said it needed an initial report of injury. Id. For numerous claims, Alta said it had not received an explanation of benefits (EOB) as required by the Commission’s rules. Id.; see also 28 Tex. Admin. Code § 133.304(c). Before the MRD issued its decision, Clarendon apparently paid many of the claims originally brought before the MRD. Alta submitted to the MRD a new, reduced chart of disputed claims. TWCC Exhibit 1, p. 15. The remaining disputed dates of service were as follows:

Date of ServiceCPT Code Amount in Dispute Requestor’s Rationale for

Increased Reimbursement

3-21-01 95935 $106.00 No EOB received

reflex studies

3-21-0195900 $128.00 No EOB received

nerve conduction, velocity, and/or latency study

3-21-0195904 $128.00 No EOB received

sensory, each nerve

3-21-0195860 $113.00 No EOB received

needle electromyography

5-31-0197250-59 $43.00 Pre-authorization received

fascial release/ soft tissue mobilization

7-9-0197122 $35.00 Provider not responsible to traction, manual give carrier report

11-8-01 97750-MT

physical $43.00

performance test No EOB received or measurement

The MRD dismissed the claims from March 21, 2001, because Alta had not provided documentation that it had submitted to Clarendon its requests for reconsideration. TWCC Exhibit 1, p. 3. The MRD denied the remaining claims because of problems with Alta’s documentation. The MRD’s record included a copy of a letter Alta had earlier sent to the Commission, stating that Clarendon had not responded to Alta’s requests for reconsideration. The MRD noted that the letter to the Commission was dated February 18, 2001, and referred to requests for reconsideration sent January 17, 2001. There was clearly something wrong, since the dates of service were from February through November 2001. The MRD therefore disregarded the letter, and recommended no reimbursement on the grounds that Alta had failed to show it had not received reconsideration EOBs. In addition, as to the May 31, 2001, date of service, the MRD noted that Alta stated the carrier had denied reimbursement because of a lack of pre-authorization, so it appeared Clarendon must have sent an EOB at some point. Since the EOB was not submitted to the MRD, the MRD recommended no reimbursement.

The parties’ positions. Dr. Higbee testified that Alta had not received EOBs for any of the disputed dates of service. With respect to the March 21, 2001, claims, Alta offered at the SOAH hearing the request for reconsideration that was not in the Commission’s certified record. Provider Exhibit 1. In reference to the claims for all four dates of service, Dr. Higbee argued that the wrong dates on the letter to the Commission documenting Clarendon’s failure to respond to the requests for reconsideration were typographical errors, and the references to “2001” should have read “2002.”[1] Therefore, according to Alta, the record adequately shows that Clarendon had not provided reconsideration EOBs. In addition, Alta asserts that it was aware that Clarendon had denied some claims for lack of pre-authorization or an initial report of injury because the carrier had provided a letter or memo, although not an actual EOB, setting out these reasons. There is such a memo saying that claims from May 31, 2001, were denied because of lack of pre-authorization. See TWCC Exhibit 1, p. 50. The record shows that on May 16, 2001, the carrier had, in fact, pre-authorized 4 weeks of chiropractic modalities. Id., p. 16. There is also a memo that says claims for E.G. cannot be processed because of a lack of a first report of injury, and that memo seems to refer in part to the________, claim. See TWCC Exhibit 1, pp. 54, 57. Finally, Alta asserts that when it submitted its new chart to the MRD, it did not also submit any new EOBs (or responses to them) that had accompanied Clarendon’s payment of most of the claims, since the MRD would not accept new evidence at that time.

Clarendon argues that SOAH has no jurisdiction to consider the dismissal of the_____, claims. And, while Clarendon acknowledges that it cannot find EOBs for the disputed claims, it asserts that there must have been EOBs. According to the carrier, when it paid most of the claims originally disputed, it would have issued EOBs for all the remaining claims. Clarendon urges that the MRD decision be affirmed.

Analysis and recommendation. As to the March 21, 2001, date of service, the ALJ believes SOAH has jurisdiction to hear an appeal of a dismissal. SOAH’s grant of jurisdiction is in the Labor Code, which says that “a party to a medical dispute that remains unresolved after a review of the medical service under this section is entitled to a [SOAH] hearing.” Tex. Lab. Code § 413.031(k).

There is no exception for dismissals.[2] Since Alta has provided the request for reconsideration as to the March 21 claims, the dismissal should be overturned.

With respect to the other three disputed claims, the MRD’s basis for denial was that Alta failed to show Clarendon had not submitted reconsideration EOBs. However, Alta’s position that the two wrong dates in its documentation were mere typographical errors is credible. The ALJ finds that the MRD was mistaken in concluding Alta’s documentation precluded recovery.

Furthermore, the record concerning the May 31, 2001, date of service shows that Clarendon denied the claim because of a supposed lack of pre-authorization, and yet the service provided on May 31 had in fact been pre-authorized. The record also shows that Clarendon had notified Alta of its reason for denial in a memo, and not in an EOB.

Finally, the complete lack in the record of EOBs for any of the four dates of service at issue leads the ALJ to the conclusion that Clarendon did not properly challenge the claims as required by the Commission’s rules. 28 Tex. Admin. Code § 133.304(c). The ALJ is not persuaded by Clarendon’s argument that “there must be” EOBs, even though Clarendon itself cannot find them.

Therefore, because the record does not support the MRD’s reasons for its decisions, and because Clarendon did an inadequate job of complying with the Commission’s rules and communicating with the provider, the ALJ determines that Alta should be reimbursed $596.00 for the disputed claims in this case.

IV. Findings of Fact

  1. The claimant _____suffered a compensable wrist injury.
  2. Clarendon National Insurance Company (Clarendon) is the workers’ compensation insurer with respect to the claims at issue in this case.
  3. Alta Healthcare Clinic, L.P., (Alta) provided treatment to the claimant on multiple dates from February through November 2001.
  4. Alta billed Clarendon for the services provided to the claimant______ in 2001. Many of the claims were not paid.
  5. In February 2002 Alta requested dispute resolution before the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission). Alta’s request stated that some claims had been denied for lack of pre-authorization, and some had been denied because the carrier had said it needed an initial report of injury. For other claims, Alta said it had not received an explanation of benefits (EOB) as required by the Commission’s rules.
  6. Before the MRD issued its decision, Alta withdrew its request for dispute resolution concerning most of the dates of service pending before the MRD.
  7. The remaining disputed claims were for: March 21, 2001 (CPT Codes 95935, 95900, 95904, and 95860); May 31, 2001 (CPT Code 97250-59); July 9, 2001 (CPT Code 97122); and November 8, 2001 (CPT Code 97750-MT). The total disputed amount was $596.00.
  8. The MRD dismissed the claims from March 21, 2001, on the grounds that Alta had failed to document that it had submitted to Clarendon its requests for reconsideration.
  9. The MRD denied the remaining claims because of problems with Alta’s documentation.
  10. Alta filed a request for hearing.
  11. Notice of the hearing was issued October 31, 2002.
  12. 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.
  13. The hearing was convened December 11, 2002, with ALJ Shannon Kilgore presiding. Ben Higbee, D.C., appeared for Alta, and Steven M. Tipton appeared for Clarendon. The hearing was adjourned and the record closed the same day.
  14. Alta sent a request for reconsideration of Clarendon’s denial of the March 21, 2001, claims.
  15. Clarendon failed to issue adequate initial or reconsideration EOBs for any of the disputed claims.
  16. Clarendon declined to pay the _________, claim for myofascial release/soft tissue mobilization because of a supposed lack of pre-authorization. Clarendon communicated this to Alta in a memo, and not an EOB.
  17. Clarendon had pre-authorized the _______, myofascial release/soft tissue mobilization.

V. 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 ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code § 413.031; Tex. Gov’t Code ch. 2003.
  3. 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. Tex. Lab. Code § 408.021.
  4. Adequate and timely notice of the hearing was provided in accordance with the Administrative Procedure Act. Tex. Gov’t Code § 2001.052.
  5. Alta has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).
  6. The Commission’s rules require both insurers and medical professionals to provide each other with certain documentation during the claims and reimbursement process, as well as to produce documentation during the medical fee dispute process. See 28Tex. Admin. Code §§ 133.304, 133.305.
  7. Based on the Findings of Fact, Alta adequately documented it had requested reconsideration for the disputed claims, and had received no reconsideration EOBs.
  8. Based on the Findings of Fact, Clarendon violated 28 Texas Administrative Code §133.304(c) and (l) by failing to provide EOBs for the disputed claims.
  9. Based on the Findings of Fact and Conclusions of Law 7 and 8, Alta is entitled to reimbursement of $596.00.

ORDER

IT IS THEREFORE ORDERED that Clarendon National Insurance Company pay Alta Healthcare Clinic, L.P., $596.00 for health care services provided to claimant __on March 21, May 31, July 9, and November 8, 2001.

Signed this 7th of February, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Shannon Kilgore
Administrative Law Judge

  1. Alta points to a certified mail receipt bearing the date January 17, 2002. The ALJ notes that the copy of this receipt in TWCC Exhibit 1 is minimally legible, but does appear to say “1-17-02.” TWCC Exhibit 1, p. 17.
  2. Furthermore, the Commission’s rules provide no recourse for a party aggrieved by a dismissal, yet at the same time give the MRD sweeping power to dismiss requests for dispute resolution. The MRD may dismiss a request for any of several listed reasons, but also upon determining “that good cause exists to dismiss the request.” 28 Tex. Admin. Code §133.305(m). The ALJ also notes that the basis for the MRD’s dismissal of the March 21 claims and the bases for its decision to recommend no reimbursement for the other three dates of service are similar, all relating to the apparent quality of Alta’s compliance with the Commission’s requirements for documentation in medical review disputes.
End of Document
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