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At a Glance:
Title:
453-03-2382-m4
Date:
May 12, 2003
Status:
Medical Fees

453-03-2382-m4

May 12, 2003

DECISION AND ORDER

Petitioner Industrial Athletics (I.A.) is seeking reimbursement of $1,585.00 for physical therapy services performed for a workers' compensation claimant from October 1, 2001, through October 19, 2001. The Administrative Law Judge (ALJ) concludes I.A. should be reimbursed $1,533.00 for those services.

I. Discussion

The Claimant was injured on_____________. He originally was scheduled for four weeks of physical therapy at I.A., but completed his treatments and returned to work after 18 days. Despite the Claimant's rapid rehabilitation, the State Office of Risk Management (SORM) denied reimbursement, saying the services were inadequately documented, whereupon I.A. filed a Request for Medical Dispute Resolution. The Medical Review Division (MRD) of the Texas Workers' Compensation Commission (TWCC or the Commission) ruled in favor of SORM, which led to the request for a hearing before SOAH.

The hearing was held April 28, 2003, with representatives of I.A. and SORM participating and ALJ Henry D. Card presiding. Both parties offered testimony and documentary evidence. The hearing was adjourned the same day.

TWCC requires physical-therapy documentation to contain the following information:

A copy of progress notes and/or SOAP (subjective/objective assessment plan/procedure) notes, which shall substantiate the care given and the need for further treatment(s) and/or services(s), and indicate progress, improvement, the date of the next treatment(s) and/or service(s), complications, and expected releasedates. . . .

28 Tex. Admin. Code (TAC)'133.1(a)(3)(E)(1).

The evidence submitted by I.A. at the hearing contains the required information for all the requested services except one. The exception was a bill for aquatics' therapy on October 2, 2001. The evidence showed that submission was in error because aquatic was not conducted on that date; the amount of that bill was $52.00.

SORM stated that neither it nor the MRD had received a substantial part of the documentation presented at the hearing. I.A. contended it submitted that material. Regardless, the documentation was adequate under the Commission's rule, and support's I.A.' s claim.

I.A. should be reimbursed in the amount of $1,533.00.

II. Findings of Fact

  1. The Claimant was injured on__________
  2. The Claimant originally was scheduled for four weeks of physical therapy at I.A., but completed his treatments and returned to work after 18 days.
  3. I.A. requested reimbursement for $1,585.00 in physical therapy services provided the Claimant from October 1, 2001, through October 19, 2001.
  4. SORM denied reimbursement, saying the services were inadequately documented, whereupon I.A. filed a Request for Medical Dispute Resolution.
  5. The MRD ruled in favor of SORM, which led to the request for a hearing before SOAH.
  6. Notice of the hearing was sent to all parties March 11, 2003.
  7. 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.
  8. The hearing was held April 28, 2003, with representatives of I.A. and SORM participating and ALJ Henry D. Card presiding. Both parties offered testimony and documentary evidence. The hearing was adjourned the same day.
  9. The documentation submitted into evidence by I.A. contained a copy of progress notes and/or SOAP (subjective/objective assessment plan/procedure) notes.
  10. The documentation submitted into evidence by I.A. substantiated the care given and the need for further treatments.
  11. The documentation submitted into evidence by I.A. indicated the Claimant's progress, improvement, the date of the next treatments, complications, and expected release date.
  12. The documentation showed that aquatic's therapy, which was billed at $52.00, was not performed on October 2, 2001.

IV. Conclusions of Law

  1. 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.
  2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  3. I.A. has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  4. I.A.’ s documentation for its requested services is adequate under 1 TAC '133.1(a)(3)(E)(1), except for the $52.00 requested for aquatics therapy for October 2, 2001.
  5. I.A. should be reimbursed in the amount of $1,533.00.

ORDER

IT IS, THEREFORE, ORDERED that the State Office of Risk Management shall reimburse Industrial Athletics the amount of $1,533.00 for physical therapy services rendered the Claimant from October 1, 2001, through October 19, 2001.

Signed this 12th day of May, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

End of Document
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