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At a Glance:
Title:
453-03-2902-m4
Date:
December 1, 2003
Status:
Medical Fees

453-03-2902-m4

December 1, 2003

DECISION AND ORDER

This case is an appeal by American Home Insurance Company (Petitioner) from the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC or Commission) in a medical fee dispute. The MRD ordered reimbursement of $35,000.00 for a pain management program. Because Petitioner pre-authorized the program, the Administrative Law Judge (ALJ) concludes that Petitioner is required to reimburse Texas Pain Medicine Clinic (Respondent) for the program.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

Notice was not contested and is discussed only in the findings of fact and conclusions of law. The hearing in this docket convened on August 20, 2003, at the State Office of Administrative Hearings, 300 West 15th Street, Austin, Texas. Petitioner was represented by attorney James Loughlin. Respondent was represented by attorney H. Douglas Pruett. The hearing concluded and the record closed on September 29, 2003, after the filing of written closing arguments.

Respondent argued that the case should be dismissed for lack of jurisdiction because Petitioner did not request reconsideration of a denial of reimbursement as required by 28 Tex. Admin. Code § 133.301(k). A review of the documentation admitted at the hearing, however, shows that Respondent substantially complied with the rule. Further, it appears that Petitioner considered Respondent in compliance in that Petitioner did not address the issue with the MRD.

II. DISCUSSION

Claimant, _____, sustained a compensable workers’ compensation injury on ______, and Petitioner pre-authorized the pain management program in dispute here. Petitioner later denied reimbursement to Respondent for the pain management program on the basis of medical necessity. Pursuant to 28 Tex. Admin. Code § 133.301(a), The insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or service(s) for which the health care provider has obtained preauthorization under Chapter 134 of this title (relating to Guidelines for Medical Services, Charges, and Payments).

Petitioner also argued that the care provided was not directly related to the compensable injury and both parties offered testimony concerning this issue. A review of the testimony indicates that the more credible evidence is that the care was directly related to the compensable injury.

III. FINDINGS OF FACT

  1. On ______, Claimant suffered a work-related injury.
  2. American Home Insurance Company (Petitioner) pre-authorized a pain management program for Claimant.
  3. Texas Pain Medicine Clinic (Respondent) provided the pain management program pre-authorized by Petitioner.
  4. Petitioner denied reimbursement to Respondent for the pain management program on the basis of medical necessity.
  5. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC or Commission) granted Respondent’s request for reimbursement.
  6. Petitioner timely requested a hearing with the State Office of Administrative
  7. Hearings,seeking review and reversal of the MRD decision.
  8. The Commission mailed notice of the hearing’s setting to the parties at their addresses on April 25, 2003. The notice of hearing listed the time, place, and nature of the hearing; included a statement of the legal authority and jurisdiction under which the hearing was to be held; referred to particular sections of the statutes and rules involved; and included a short, plain statement of the matters asserted.
  9. A hearing in this matter was convened on August 20, 2003, at 300 West 15th Street, Austin, Texas. Petitioner and Respondent participated in the hearing and the record closed on September 29, 2003, after the filing of written closing arguments.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction over this matter pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, Tex. Gov’t Code Ann. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and the Commission’s rules, 28 Tex. Admin. Code § 133.305(g) and §§148.001-148.028.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§2001.051 and 2001.052.
  5. Pursuant to 28 Tex. Admin. Code §133.301(a), “the insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or service(s) for which the health care provider has obtained preauthorization under Chapter 134 of this title (relating to Guidelines for Medical Services, Charges, and Payments).”
  6. Based upon the Findings of Fact and Conclusions of Law, Petitioner’s appeal of the decision ordering reimbursement should be denied, and Petitioner should be required to reimburse Respondent for the pain management program provided to Claimant by Respondent.

ORDER

IT IS THEREFORE, ORDERED that Petitioner, American Home Insurance Company, is required to pay reimbursement of $35,000.00 plus all accrued interest to Respondent for the pain management program provided to Claimant.

Signed this 1st day of December, 2003.

JOHN H. BEELER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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