Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-03-3608-m4
Date:
September 26, 2003
Status:
Medical Fees

453-03-3608-m4

September 26, 2003

DECISION AND ORDER

Texas Mutual Insurance Company challenges a decision of the Texas Workers’ Compensation Commission’s Medical Review Division ordering reimbursement of $384.00 to Health & Medical Practice Associates for medical services provided on March 26, 2002, and April 15, 2002. As reflected in the Findings of Fact and Conclusions of Law, the Administrative Law Judge (ALJ) concludes that because the doctor who rendered the services was not the treating doctor on the two dates of service, reimbursement should be denied.

I. FINDINGS OF FACT

  1. On March 26, 2002, and April 15, 2002, Maxie Sprott, M.D., provided medical services to a worker who had sustained an on-the-job injury covered by workers’ compensation insurance.
  2. At the time of the injury, Texas Mutual Insurance Company (ATexas Mutual) provided workers’ compensation insurance coverage to the worker’s employer.
  3. On March 26, 2002, and April 15, 2002, Maxie Sprott, M.D., was not the injured worker’s treating doctor.
  4. The hearing in this case convened and closed on September 4, 2003, before ALJ Gary Elkins. Texas Mutual appeared and was represented by Attorney Patricia Eads. Susanna Hamlin appeared on behalf of Health and Medical Practice Associates.

II. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide issues relating to preauthorization, pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. The State Office of Administrative Hearings has jurisdiction over matters relating to preauthorization, including consideration of jurisdictional challenges, and has the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. '' 402.073 and 413.031(d), and Tex. Gov’t Code Ann. ch. 2003.
  3. Except in an emergency, all health care must be approved or recommended by the employee's treating doctor. Tex. Labor Code Ann. ' 408.021(c).
  4. Based on Findings 1 and 3 and Conclusion 3, Texas Mutual is not liable to Health & Medical Practice Associates for the services rendered by Maxie Sprott, M.D., on March 26, 2002, and April 15, 2002.

ORDER

IT IS ORDERED that the request for reimbursement of Health & Medical Practice Associates for services rendered by Maxie Sprott, M.D., on March 26, 2002, and April 15, 2002, is denied.

Signed this 26th day of September 2003.

GARY W. ELKINS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
Top