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At a Glance:
Title:
453-03-3297-m4
Date:
September 6, 2007
Status:
Medical Fees

453-03-3297-m4

September 6, 2007

DECISION AND ORDER

I. INTRODUCTION

In a decision dated April 15, 2003, the Medical Review Division (MRD) of the Texas Workers' Compensation Commission[1] (Commission) denied the request for additional reimbursement filed by Vista Medical Center Hospital (Vista) for services it provided to a workers’ compensation claimant during an inpatient hospital admission on August 18 through 28, 2001. MRD found that because Vista’s request was received on August 21, 2002, the only dates of service eligible for review were those commencing on August 21, 2001 and following.[2] MRD was unable to determine whether Vista’s charges for those days exceeded $40,000 because Vista’s line item bill was partially illegible.

In this Decision and Order, the Administrative Law Judge (ALJ) finds that the charges for the dates of service from August 21 through 28, 2001, were less than the amount the Carrier, Texas Mutual Insurance Company, has already reimbursed Vista. Vista’s bill submitted in this case is

legible.[3] It shows that Vista billed twice for room and board provided on August 21, 2001. When the second charge is omitted from the bill, total charges for August 21 through 28, 2001, equal approximately $7,380. Thus, since TMIC has already reimbursed Vista for more than that amount, the ALJ finds that Vista has not met its burden of proving it is entitled to additional reimbursement.

II. PROCEDURAL HISTORY, NOTICE, AND JURISDICTION

Notice and jurisdiction were not contested and are discussed only in the Findings of Fact and Conclusions of Law. Attorneys Thomas B. Hudson, Jr., and Christopher H. Trickey represented TMIC, and attorney David F. Bragg represented Vista.

This case was consolidated with Docket No. 453-03-2412.M4 for the purpose of resolving preliminary legal issues, and the order addressing those issues, Order No. 14 in Docket No. 453-04-2412.M4, was issued November 22, 2005. The parties were advised to request dates for a hearing on the merits, but, instead, they asked that this case be abated while a similar case was appealed. Their request was granted, and this case was abated from February 21, 2006, to April 4, 2007, when it was reinstated on the docket. After the case was reinstated on the docket, the parties elected to file written stipulations of fact and closing arguments, rather than having a contested case hearing. The record closed on July 9, 2007.

The parties attached exhibits to their stipulations, and those documents are admitted as Exhibit A. In addition, 36 numbered exhibits were admitted during the preliminary hearing.

III. FINDINGS OF FACT

  1. A workers’ compensation claimant was injured on ____, while working for an employer who carried workers’ compensation insurance with Texas Mutual Insurance Company (TMIC).
  2. On August 18, 2001, the claimant was admitted to Vista Medical Center Hospital (Vista) and underwent back surgery to treat his work-related injury.
  3. The claimant was discharged from Vista on August 28, 2001.
  4. Vista charged $139,105.58 for the services rendered to claimant from August 18 through 28, 2001.
  5. TMIC reimbursed Vista $21,639.52 of the amount Vista billed.
  6. On August 21, 2002, Vista filed a request with the Medical Review Division (MRD) of the Texas Workers' Compensation Commission (Commission) asking that TMIC be ordered to reimburse Vista an additional $82,689.67, which is 75% of the total amount billed, less the amount TMIC had paid.
  7. In a decision dated April 15, 2003, MRD denied the request for additional reimbursement, and Vista requested a contested case hearing before the State Office of Administrative Hearings (SOAH).
  8. Notice of the hearing on Vista’s appeal, dated May 29, 2003, was sent to both parties. 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.
  9. On August 13, 2003, this case was consolidated with Docket No. 453-03-2412.M4, for the purpose of resolving threshold legal issues.
  10. Order No. 14 in Docket No. 453-03-2412.M4 was issued November 22, 2005. The order resolved legal issues pertaining to this case and advised the parties to request hearing dates.
  11. Based upon the parties’ joint request, this docket was abated from February 21, 2006, to April 4, 2007, when the case was reinstated on the docket.
  12. After the case was reinstated on the docket, the parties elected to file written stipulations of fact and closing arguments in lieu of a contested case hearing.
  13. Attorneys Thomas B. Hudson, Jr., and Christopher H. Trickey represented TMIC, and attorney David F. Bragg represented Vista.
  14. Because MRD received Vista’s request for medical dispute resolution on August 21, 2002, the only dates of service eligible for review are August 21 through 28, 2001. 28 Tex. Admin. Code (TAC) § 133.305 (West 1999).
  15. Vista’s total charges for August 21 through 28, 2001, are less than $21,639.52.
  16. Vista’s charges for the dates of service from August 21 through 28, 2001, were less than the amount TMIC has already reimbursed Vista.

IV. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq. (Vernon’s 2003).
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(k) and Tex. Gov’t Code Ann. ch. 2003 (Vernon’s 2003).
  3. Vista had the burden of proof in this case. 28 TAC § 148.14.
  4. Vista failed to meet its burden of proving it is entitled to additional reimbursement.

ORDER

IT IS, THEREFORE, ORDERED that Vista Medical Center Hospital’s request for additional reimbursement is denied.

Signed September 6, 2007.

SARAH G. RAMOS

ADMINISTRATIVE LAW JUDGE STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Effective September 1, 2005, the functions of the Commission were transferred to the newly-created Division of Workers' Compensation at the Texas Department of Insurance.
  2. A request for review of medical services and dispute resolution must be submitted to the Commission no later than one calendar year after the dates of service in dispute. 28 Tex. Admin. Code § 133.305 (West 1999).
  3. Ex. A, RD-079 et seq.
End of Document
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