DECISION AND ORDER

Dillards Department Stores, a self-insured entity (Carrier), challenged the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) awarding additional reimbursement to Huguley Memorial Hospital (Hospital) for costs billed for the hospitalization of ___ (Claimant) for a spine surgery. The MRD concluded that Hospital was entitled to additional payment as it qualified for payment under the stop-loss reimbursement method provided for in 28 Tex. ADMIN. Code § 134.401, the Acute Care Inpatient Hospital Fee Guideline (HFG or Rule 134.401). Carrier had reimbursed Hospital under the per diem method.

Based on the evidence, Carrier failed to meet its burden of proof to show it had authority to use the per diem method to reimburse Hospital for Claimant’s stay.^[1] Carrier must pay Hospital additional reimbursement in the amount of $57,045.48, the difference between the amount it paid and the amount Hospital is entitled to be paid under the stop-loss computation set forth in Rule 134.401(c)(6)(B).

The hearing in this matter convened on August 25, 2004, in Austin, Texas, with Administrative Law Judge (ALJ) Cassandra Church presiding. The record closed on September 3, 2004, the date parties filed closing argument. Hospital was represented by Phillip E. Cannatti, attorney. Carrier was represented by Jack W. Latson, attorney. The Commission did not participate in the hearing.

Matters of jurisdiction and notice were not disputed, so are set forth in the Findings of Fact and Conclusions of Law without further discussion here.

I. DISCUSSION

Background

Claimant, Carrier’s employee, was admitted to the Hospital on October 23, 2001, as a

surgical patient. Claimant was admitted for performance of spinal stabilization and fusion on several lower spine levels. These procedures included instrumentation. Hospital supplied the surgeon with

the devices installed in Claimant’s body, i.e., a rod, screws, two stabilization cages or meshes, and bone material. Hospital billed Carrier directly for these devices in the amount of $69,743.80.

Claimant was discharged on October 29, 2001. Hospital’s total charge for Claimant’s six-day stay was $94,689.05, for which it sought reimbursement from Carrier under the stop-loss method. That method provides that hospital bills over $40,000, after audit, shall be reimbursed at 75 percent of audited charges.^[2] Carrier did not perform an on-site audit of the bill, but did conduct a bill review. In that review, Carrier concluded Hospital should be reimbursed using the per diem method because it determined that the services were not unusually costly or extensive, or the stay unusually lengthy, within the meaning of Rule 134.401(c)(6)(B). Carrier also concluded that Hospital’s bill, as recalculated by Carrier, was under $40,000. Carrier arrived at this figure by recalculating the value of Hospital’s implantable charges at cost plus 10 percent. Cost plus 10 percent is the amount authorized under the per diem method to reimburse hospitals for certain qualifying items. Implantables are an item qualifying for additional reimbursement above and beyond the Hospital’s daily charges under the per diem method.^[3] Hospital’s acquisition cost of the implantables was $6,603. The cost plus 10 percent amount was thus recalculated by Carrier to be $7,263.30.^[4]

After Carrier recalculated the price of the implantables, Carrier also recalculated the cost of the per-day charges for a six-day surgical stay by applying the $1,118 daily rate provided for under the per diem method. Carrier then added the recalculated daily rate, $6,708.00, and the implantable amount, $7,263.30, to arrive at the reimbursement amount of $13,971.30, which it paid Hospital. Carrier denied the remainder of the claim as being contrary to the HFG.

Hospital appealed Carrier’s partial denial to the MRD. On February 2, 2004, the MRD determined that charges arising out of Claimant’s hospitalization were entitled to be reimbursed under the stop-loss method. The MRD ordered Carrier to reimburse Hospital the additional amount of $57,045.58, the difference between what it paid and what would have been due under the stop-loss method.^[5] The MRD also held that Carrier could not “carve out” implantables and re-price them in

order to make its decision on the applicability of the stop-loss method. The MRD also held that the Hospital had billed its usual and customary charges. On February 4, 2004, Carrier requested a contested case for reconsideration of the MRD decision.

Summary of Issues

The first issue presented by this case was the legal issue of whether Hospital’s charges were sufficient to trigger the application of the stop-loss method of reimbursement or whether it also had to demonstrate additional elements concerning the nature of the care provided in order to qualify for reimbursement under this method. The second issue presented is whether Carrier had the authority

to carve out and recalculate the cost of implantables in order to arrive at the amount of audited charges in aid of determining whether Hospital qualified for reimbursement under the stop-loss method.^[6]

The parties agreed that a hospital must charge its usual and customary fees in order to qualify for reimbursement.

Parties’ Positions

Carrier argued that there are two criteria a hospital must meet in order to qualify for reimbursement using the stop-loss method and that Hospital had met neither. First, a hospital must demonstrate that the stay involved procedures or services that were unusually extensive^[7] or unusually costly.^[8] Second, a hospital must submit a bill showing charges, after audit, of over $40,000, exclusive of items classified by the HFG as “additional items.” Carrier argued that considering the dollar amount as the only triggering factor ignores other principles in the Commission’s overall health care reimbursement scheme, i.e., containing medical costs and avoiding a grant of unchecked authority to providers to charge prices unrelated to the actual cost of providing care.^[9] Carrier argued that in this case, Hospital had failed to demonstrate that the procedures performed or services provided were either unusually costly or unusually extensive, or the stay lengthy, thereby failing to qualify for stop-loss reimbursement on substantive grounds. It also argued that Hospital’s bill did not meet the dollar threshold after implantables were deducted and recalculated.^[10] Carrier argued there was a presumption in favor of per diem compensation.

Carrier also argued that the general grant of authority to carriers to conduct bill reviews permitted its practice of assessing the nature of the services and also of recalculating implantable costs before determining whether a bill qualified for stop-loss reimbursement. Carrier did not dispute the fact that the HFG does not expressly provide for either step in conducting a bill review. Notwithstanding that, Carrier argued its practices were consistent with the provisions in the Texas Labor Code requiring provision of appropriate care at reasonable costs. Carrier argued that such a

requirement should be inferred from a broad reading of Rule 134.401 in concert with the Labor

Code. It argued that to find otherwise would result in a rule that exceeded the mandate in the Labor Code to provide for reasonably-priced health care for injured workers.

For its part, Hospital argued that there are only two factors relevant to determining whether the stop-loss method applies and that it met both of them. The first factor is the total amount of the bill which must exceed the threshold amount of $40,000, after audit. The second is whether the hospital charged its usual and customary charges. Hospital argued since its bill was over the $40,000 threshold and Carrier had not reduced that bill by any allowable audit deductions, and since its charges were its usual and customary rates, it should have been reimbursed using the stop-loss formula. Hospital asserted that Rule 134.401 does not require a hospital to demonstrate additional facts about the nature of the admission or procedures in order to qualify for stop-loss payment. Hospital also disputed that the rule contains a presumption in favor of per diem compensation.

In addition, Hospital asserted that the Commission’s bill-auditing rules do not authorize a carrier to recalculate the cost for implantables using the cost plus 10 percent method before it makes a decision on whether a hospital’s bill has reached the stop-loss threshold. Hospital argued that Carrier’s only valid grounds for avoiding payment under the stop-loss method in this case would have been to demonstrate that Hospital’s charges for the implantables were not its usual and customary charges and that Carrier had failed to do so.^[11]

Hospital also argued that in fee disputes on this issue, the Commission has consistently barred carriers from “carving out” implantables when determining whether the stop-loss alternative should be applied. Hospital argued the agency’s interpretation of this rule is entitled to deference.

Applicable Authority

The HFG sets forth the step-by-step procedures for submitting and paying hospital bills for injured workers.^[12] For the most part, it outlines the procedures to be used by providers and carriers for filing for and paying reimbursement. However, the passages of Rule 134.401 pertaining to the stop-loss method contain both objectives and procedures.

The steps for this reimbursement method are as follows:

• Stop-loss is an independent methodology established to ensure fair and reasonable compensation to the hospital for an unusually costly or lengthy hospital stay.^[13]
• Stop-loss is to be used in place of and not in addition to the per diem based reimbursement system.^[14]
• The stop-loss threshold is established to ensure compensation for unusually extensive services required during an admission.^[15]

The mechanics for applying this reimbursement method are as follows:

• Submission of a bill containing audited charges in excess of $40,000.^[16]
• Determination that the charges are the hospital’s ”usual and customary charge.”^[17]

The steps for arriving at the audited charges are as follows:

• Carrier may deduct personal items, line items for services not rendered, and charges unrelated to the compensable injury.^[18]
• Carrier may deduct items which would be subject to audit as described in Commission rules, specifically 28 Tex. ADMIN. Code133.301(a) which provides for review for unbundling, services unrelated to the injury, and the like.^[19]

E. Discussion

Qualification for Stop-Loss Reimbursement

In arguing for a two-step qualification process, Carrier relied on its reading of the Labor Code and evidence regarding the Commission’s intent in adopting Rule 134.401. As noted above, Carrier

argued that a rule which appears to provide no cost containment checks and balances is contrary to

the tenets of the Labor Code.^[20] In addition to its legal arguments, Carrier offered the testimony of Julie Shank, R.N. Ms. Shank worked for the Commission at the time the HFG and other fee guidelines were being written and assisted in researching and drafting these guidelines. Since

leaving the Commission, she has been employed as consultant on medical benefit issues. She reviewed Hospital’s bill for stop-loss qualification but did not audit the bill for other errors.

Ms. Shank testified that it was her belief that the intent of the Commission was to treat potential stop-loss cases like hospital stays for catastrophic injuries. She contended that it was the Commission’s intention that in order to qualify for the more-generous compensation levels of the stop-loss method, hospitals would have to demonstrate a medical basis for why a hospital stay not in one of the defined catastrophic categories warranted stop-loss treatment. The stop-loss provisions in the workers’ compensation system were modeled on stop-loss provisions in insurance contracts with other types of payors.

Carrier also offered the testimony of Michael M. Albrecht, M.D., an orthopedic surgeon. After reviewing the records, Dr. Albrecht concluded Claimant’s treatment and recovery were not out of the ordinary for a patient with the condition she presented.

For its part, Hospital relied primarily on the plain language of the HFG, arguing that Carrier provided no justification for reading additional requirements into Rule 134.401. Hospital argued that restrictions could have been put in the HFG but that they were not. Hospital also argued that the rule does not contain any preference for the per diem method.

Carrier’s argument that this rule tips the balance too far away from cost containment may carry considerable weight in another forum, but it lacks merit here. Carrier is asking the ALJ to substitute her interpretation of the purpose and objectives of Rule 134.401 for that of the Commission without demonstrating there is any conflict between the rule and a provision in the Labor Code or even any ambiguity in the language of the rule itself.^[21] The detailed preamble to the HFG discusses the Commission’s efforts to achieve a balance among the many conflicting objectives

of the Act.^[22] Those efforts resulted in the language in Rule 134.401. Given the straightforward language in Rule 134.301, the ALJ concludes this rule should be applied as written in order to effect

the Commission’s conclusions on how to carry out the mandates of the Labor Code.^[23]

Carrier’s evidence on this point, Ms. Shank’s testimony, is not determinative notwithstanding her considerable expertise in the field. Any individual author’s recollection of the intent of a rule does not substitute for what actually was adopted by the Commission after full opportunity for public comment and Commission reconsideration and revision.^[24] Further, Ms. Shank’s tenure at the Commission ended in 1996, before the agency implemented the 1997 HFG, so she did not participate in Commission decision-making on application of this rule.

The ALJ concludes that Rule 134.401 does not set up a multi-stage test for a hospital’s bill to be considered eligible for reimbursement under the stop-loss alternative. The ALJ concludes that threshold for application of the stop-loss method can be comprehended by application of the plain meaning of the language in the rule. This rule provides for a $40,000 threshold of charges that are the hospital’s usual and customary charges, after audit.

Permissible Methods to Determine the Audited Charges

Carrier made primarily a legal argument that under its general audit authority it had authority to determine the best means to meet the Commission goals of cost containment, so it could re-price Hospital’s charges on implantables.

Hospital relied on the language of Rule 134.401 which does not expressly authorize a carrier to reach into the per diem method in order to recalculate a hospital bill. Hospital also argued that the agency has on many occasions held such a “carve out” is inappropriate. ^[25]

Based on the agency decisions cited by Hospital in its brief, it appears the conclusion reached by the MRD in this case was consistent with many other Commission decisions on this point. An agency’s interpretation of its rule and, by extension, its enabling statue is entitled to some

deference.^[26]

In addition, the internal language and structure of Rule 143.301 seem to prohibit Carrier from recalculating a provider’s bill on a line-item basis. First, there is no provision in this rule that permits a carrier to carve out a category of items and apply a pricing or costing method drawn from another category of reimbursement before the bill’s qualification for payment under the stop-loss method applies. Second, the language of Rule 134.401 specifies in more than one place that the stop-loss and per diem methods are exclusive of one another.^[27] For example, the provision regarding the computation of “additional reimbursements” at cost plus 10 percent for a number of items, including implantables, is applicable “only to bills that do not reach the stop-loss threshold described in subsection (c)(6) of this section.”^[28] The language in this section is straightforward.

Even considering Carrier’s general bill review and audit authority in its most favorable light, the ALJ is unable to find authority for the proposition that Carrier has authority to simply recalculate a line item in a provider’s bill by drawing on a methodology from a separate compensation scheme. Auditing authority in the Commission’s rules give a carrier a number of ways to challenge the appropriateness or accuracy of a provider’s bill, i.e,. it contradicts a fee guideline, was not a usual and customary charge, was bundled, etc. However, there is nothing in the HFG to suggest what Carrier did in this case is an authorized means of conducting a bill review or that the per diem method to cost “additional items” constitutes a general implantables rate to be used in the auditing process for all purposes.

The ALJ concludes that neither Rule 134.401 nor the general audit authority permit a carrier to recalculate the value of a particular hospital bill line item under the cost plus 10 percent method in order to arrive at the threshold amount of the bill for consideration of stop-loss application.

Usual and Customary Charges

Carrier did not present sufficient evidence to show that Hospital’s charges were not the same as those that it would have charged any other payor for the same services and items. Neither Ms. Shank nor Dr. Albrecht testified on that point. There were no documents showing that Hospital actually billed another payor a different amount. The MRD concluded the charges were usual and customary.

The ALJ concludes Hospital billed Carrier its usual and customary charges for the services and items used in Claimant’s hospitalization.

Summary

In summary, the ALJ concludes that Carrier did not act within the scope of its auditing authority when it recalculated Hospital’s implantable cost under the cost plus 10 percent method to determine whether Hospital qualified for the stop-loss level of reimbursement. Carrier did not act in

accord with Rule 134.302(c)(6) when it denied payment under the stop-loss method on the basis that Hospital had failed to make additional factual showings concerning the nature and extent of the

procedure. Carrier did not demonstrate that Hospital’s charges were not its usual and customary charges. Based on the above, the ALJ concludes that Carrier should reimburse Hospital the additional amounts that would be due under the stop-loss method of reimbursement provided for in Rule 134.401(c)(6).

II. FINDINGS OF FACTS

1. On ___, ___ (Claimant) suffered a compensable injury to her back.
2. Dillards Department Stores, a self-insured entity (Carrier), was the responsible insurer.
3. On October 23, 2001, Claimant was admitted to Huguley Memorial Hospital (Hospital) as a surgical patient for a six-day stay. She was discharged on October 29, 2001.
4. Claimant was diagnosed as having spinal stenosis, degenerative disk and joint diseases of the lumbar spine, and discogenic and mechanical back pain. Claimant had been treated conservatively during the eight years between her injury and the October 2001 surgery but continued to have back pain.
5. While a patient at the Hospital, Claimant underwent spinal surgery. John A. Sazy, M.D., performed a laminectory, a bilateral foraminotomy, and a posterior spinal fusion at the L1-S1 levels, and an interbody fusion at the L4-5 and L5-S1 levels.
6. The surgery included permanent insertion of various items of instrumentation (implantables) into or near Claimant’s spine. The items used in this case included at least two spine-stabilizing meshes or cages into which bone grafts were inserted, screws, a supporting rod, and bone grafting material.
7. Hospital’s acquisition cost for the implantable material was $6,603.
8. Hospital supplied the implantables that Dr. Sazy used. Hospital billed Carrier directly for these devices in the amount of $69,743.80. The total bill for the hospital stay, including implantables, was $94,689.05.
9. All charges made by Hospital were that facility’s usual and customary charges for services and items provided for a surgical admission.
10. Claimant began walking three days after the operation, and for the remaining four days increased her walking, endurance, and stamina. She did not suffer any reverses, infections, or other complications of the surgery while a Hospital patient.
11. Carrier did not conduct an on-site audit of Hospital’s bill for Claimant’s care; Carrier conducted a bill review limited to Hospital’s qualification for stop-loss reimbursement.
12. In its bill review, Carrier determined that Claimant’s hospital stay was not lengthy, and that the services provided were neither unusually extensive or costly treatment for the spine condition Claimant presented. The amount billed for service, exclusive of implantables, was $24,945.25, which Carrier determined not sufficient to meet the dollar threshold of $40,000.
13. Carrier reimbursed Hospital $13,971.30 and denied payment for all amounts above that amount the basis that the charges were inconsistent with Commission’s Acute Care Inpatient Hospital Fee Guideline (HFG), 28 Tex. Admin. Code § 134.401.
14. Carrier arrived at the reimbursement amount of $13,971.30 by first recalculating the value of the implantables at cost plus 10 percent, a method provided for in 28 Tex. Admin. Code § 134.401(c)(4) for additional items under the per diem method. It also recalculated the cost for basic hospital services using the daily rate of $1,118 for surgical admissions under the per diem method. The amount of the former was $7,263.30, and the amount of the latter was $6,708.00.
15. The only purpose stated in the HFG for cost plus 10 percent valuation of implantables is as a means of supplementing the per diem charges for certain qualifying items when the per diem reimbursement method is used.
16. On January 30, 2004, the MRD ordered Carrier to reimburse Hospital an additional $57,045.48, which would compensate Hospital at the rate provided for under the stop-loss method of reimbursement. The MRD held that Carrier had incorrectly carved out the implantable costs before it determined which reimbursement method to apply under the HFG and also held that Hospital’s charges were usual and customary.
17. On February 4, 2004, Carrier requested a hearing on the MRD decision.
18. On March 2, 2004, the Commission issued a notice of hearing that included the date, time, and location of the hearing, the applicable statutes under which the hearing would be conducted, and a short, plain statement of matters asserted. The case was continued on motion of the parties.
19. Administrative Law Judge Cassandra Church conducted a hearing on the merits of this case on August 25, 2004, and the record closed September 3, 2004, the date the parties filed closing argument.

III. CONCLUSIONS OF LAW

1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in 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.
2. Carrier timely requested a hearing, as specified in 28 Tex. Admin. Code § 148.3.
3. Proper and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann.§§ 2001.051 and 2001.052.
4. Carrier, as the petitioning party, has the burden of proof in this proceeding pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin. Code § 148.21(h).
5. Carrier failed to meet its burden of proof to show it had authority under 28 Tex. Admin. Code 134.401 to use the cost plus 10 percent method to recalculate the value of implantables supplied by Hospital to order to determine Hospital’s qualification for payment under the stop-loss method.
6. Carrier failed to meet its burden of proof to show it had authority under 28 Tex. Admin. Code §§ 133.301 or 134.401 to use the per diem method to reimburse Hospital for Claimant’s surgical hospital admission from October 23-29, 2001.
7. Hospital’s charges of $94,689.05 for Claimant’s surgical hospital admission from October 23-29, 2001, met the threshold for reimbursement under the stop-loss method of compensation set forth in 28 Tex. Admin. Code § 134.401(c)(6).

ORDER

IT IS ORDERED that Dillards Department Stores, a self-insured entity, reimburse Hugely Memorial Hospital a total of $57,045.48, plus accrued interest, for Claimant ___’s surgical hospital admission from October 23-29, 2001.

Signed November 2, 2004.

CASSANDRA J. CHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. At the contested case hearing, the ALJ assigned the burden of proof to Carrier as it was the party seeking relief from an adverse decision of the MRD. Tex. Lab. Code Ann. § 413.031, 28 Tex. ADMIN. Code §§ 148.21(h).↑
2. 28 Tex. Admin. Code § 134.401(c)(6) (A) – (C).↑
3. 28 Tex. Admin. Code § 134.401(c)(4). Other qualifying items include orthotics and prosthetics.↑
4. Carrier Exh. 4.↑
5. As Carrier did not audit Hospital’s bill for any reason other than qualification for stop-loss, Carrier did not reduce Hospital’s bill on any other grounds. Thus, in this case, the Hospital’s initial bill was the “audited charges.” The MRD applied the stop-loss formula, multiplying the $94,689.05 (audited charges) x 75 percent (stop-loss reimbursement factor) = $71,016.78 (workers’ compensation reimbursement amount). As Carrier had already paid Hospital $13,971.30, the MRD ordered Carrier to pay Hospital the difference between those two figures, $57,045.48, plus accrued interest.↑
6. 28 Tex. Admin. Code § 134.401(c)(6)(A)(v).↑
7. 28 Tex. Admin. Code § 134.401(c)(6)(A)(ii).↑
8. 28 Tex. Admin. Code § 134.401(b)(1)(F) and (c)(6).↑
9. The Texas Workers’ Compensation Act (the Act) has several objectives in addition to controlling costs, including providing compensation for health care providers that is fair and reasonable and ensuring quality of medical care for injured Texas workers. Tex. Lab. Code Ann. § 413.011 (d) – (g).↑
10. Carrier took the position that it should be able to reimburse implantables at cost plus 10 percent even if the services were sufficiently costly or extensive to merit stop-loss reimbursement. It argued further that it should be the remainder of the billBminus the implantables or other qualifying additional itemsBthat would determine whether a hospital met the $40,000 threshold.↑
11. 28 Tex. Admin. Code § 134.401(b)(2).↑
12. 28 Tex. Admin. Code § 134.401.↑
13. ¹⁰ 28 Tex. Admin. Code §§ 134.401(b)(1)(F) – (H) and (c)(6).↑
14. ¹¹ 28 Tex. Admin. Code § 134.401(c)(6).↑
15. ¹² 28 Tex. Admin. Code § 134.401(c)(6)(A)(ii). There is yet a third category of reimbursement created for hospital care for patients with specified diagnoses, i.e., trauma, burns, and human immunodeficiency virus. 28 Tex. Admin. Code § 134.401(c)(5). Those costs are reimbursed at “a fair and reasonable rate.” 28 Tex. Admin. Code § 134.401(c)(6).↑
16. ¹³ 28 Tex. Admin. Code § 134.401(c)(6)(A)(i).↑
17. ¹⁴ 28 Tex. Admin. Code § 134.401(b)(2)(A).↑
18. ¹⁵ 28 Tex. Admin. Code § 134.401(c)(6)(A)(v).↑
19. ¹⁶ 28 Tex. Admin. Code § 134.401(b)(2)(C). Under Rule 133.301(a), a carrier’s audit of a hospital bill may include examination for:

(1) compliance with the fee guidelines established by the Commission;

(2) compliance with the treatment guidelines established by the Commission;

(3) duplicate billing;

(4) upcoding and/or unbundling;

(5) billing for treatments and services unrelated to the compensable injury;

(6) billing for services not documented or substantiated, when documentation is required in accordance with Commission fee guidelines or rules in effect for the dates of service;

(7) accuracy of coding in relation to the medical record and reports;

(8) correct calculations; and/or

(9) provision of unnecessary and/or unreasonable treatment(s) and/or services.↑

20. ¹⁷Compare SOAH Docket Nos. 453-03-0910.M4 (April 2003, Sullivan), 453-01-1612.M4 (September 2001, Cunningham), and 453-00-2092.M4 (April 2001, Cunningham).↑
21. ¹⁸See Seminole Pipeline Co., et al, v. Broad Leaf Partners, Inc., 979 S.W.2d 730, 751 (Civ. App.BHouston [14^th] 1998). (By giving effect to the legislative intent, i.e., that the [damages] cap should apply on a “per defendant” basis, we realize our decision renders the statute wholly ineffective in achieving the legislative objective of establishing greater predictability. Still, the task of drafting effective legislation rests with the legislature, not this court.)↑
22. ¹⁹ 22 Tex Reg. 6264-6305 (July 4, 1997). The preamble to this rule specifies the objectives balanced by the Commission:

The Commission considered all relevant statutory and policy standards and objectives and designed this new rule to achieve those standards and objectives, including the following:

(1) establish guidelines relating to fees charged or paid for medical services for employees who suffer compensable injuries, including guidelines relating to payment of fees for specific medical treatments or services;

(2) ensure that injured workers receive the health care reasonably required by the nature of their injury, as and when needed;

(3) ensure guidelines for medical services fees are fair and reasonable;

(4) design fee guidelines to ensure quality health care to the injured workers of Texas;

(5) design fee guidelines to achieve effective medical cost control;

(6) ensure that guidelines for medical services fees do not provide for payment of a fee in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or someone acting on that individual’s behalf;

(7) consider the increased security of payment afforded by the Act in establishing the fee guidelines;

(8) maintain a statewide database of medical charges, actual payments, and treatment protocols that may be used by the Commission in adopting medical fee guidelines;

(9) ensure the Commission’s database contains information necessary to detect practices and patterns in medical charges and actual payments; and

(10) ensure the Commission’s database can be used in a meaningful way to allow the Commission to control medical costs as provided by the Act. (22 Tex Reg. 6267)↑

23. ²⁰ See SOAH Docket Nos. 453-03-1233.M4 (October 2003, Walston) and 453-04-4223.M4 (August 2004, Card).↑
24. ²¹General Chemical Corp. vs. De La Lastra, 852 S.W.2d 916, 923 (Tex. 1993).↑
25. ²² See MRD Decisions M4-02-2115-01 (August 15, 2002), M4-02-4514-01 (March 27, 2003), M4-02-4838-01 (April 4, 2003), and M4-03-1552-01 (May 30, 2003), published at www.twcc.state.tx.us.↑
26. ²³ Contemporaneous construction of a statute by administrative agency charged with its enforcement is entitled to great weight. State v. PUC, 883 S.W.2d 190 (Tex. 1994). To be given weight, the agency’s interpretation must be reasonable and not contradict the plain language of the statute, Tarrant Appraisal Dist. v . Moore, 845 S.W.2d 820 (Tex. 1993); Dodd v. Meno, 870 S.W.2d 4 (Tex. 1994), neither expand nor contract the language of the statute, Firestone Tire & Rubber Co. v. Bullock, 573 S.W.2d 498 (Tex. 1978), or be clearly inconsistent with legislative intent. Texas Water Comm’n v. Brushy Creek MUD,917 S.W.2d 19 (Tex. 1996).↑
27. ²⁴ 28 Tex. Admin. Code § 134.401(c)(6).↑
28. ²⁵ 28 Tex. Admin. Code §§ 134.401(c)(4) and (c)(6).↑