DECISION AND ORDER
Hill Country Healthcare (Provider) challenges the denial of reimbursement by _______(_____), a self-insured entity, for services provided to an injured worker because the Provider failed to obtain preauthorization. The Administrative Law Judge (ALJ) concludes that Provider did not obtain proper preauthorization. Consequently, Provider is not entitled to reimbursement.
I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY
There are no issues of notice or jurisdiction in this proceeding. Therefore, these matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.
Provider filed a request for medical fee dispute resolution with the Texas Department of Insurance, Division of Workers’ Compensation (Division). On April 30, 2012, the Division issued its Medical Fee Dispute Resolution Findings and Decision. On May 9, 2012, Provider requested a hearing at the State Office of Administrative Hearings (SOAH) to contest the Division’s determination. On May 11, 2012, the Division issued a Notice of Hearing. A hearing convened before ALJ Wendy Harvel on August 23, 2012, at SOAH’s facilities in Austin, Texas. The record closed the same day. Provider was represented by Arturo Gonzales. ____ was represented by its legal counsel, James Loughlin.
II. DISCUSSION
A.Applicable Law
“An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.”[1] Specifically, the employee is entitled to health care that: “(1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.”[2]
An insurance carrier is liable for all reasonable and necessary medical costs of chronic pain management when those services have been preauthorized.[3] Chronic pain management performed without preauthorization is not reimbursable.
B.Summary of the Evidence
Claimant, an injured worker, suffered a compensable injury on ___. Provider sought preauthorization for chronic pain management sessions of eight hours per day for ten days from November 25, 2008, through December 31, 2008. At the time of injury, Claimant was an employee of ___. However, Provider’s preauthorization request indicated that Claimant was employed by ___, and Provider submitted the preauthorization request to Review Med, the preauthorization agent for ___. Provider did not submit the preauthorization request to the preauthorization agent for ___.
C.Analysis and Decision
Provider argues that it received preauthorization. The fact that the preauthorization came from an entity other than ___, the self-insured entity covering the Claimant, is irrelevant, according to Provider. Carrier disagrees and argues that it never granted preauthorization for the services.
The ALJ finds that Provider failed to show it received preauthorization from ___ for Claimant’s pain management services. The fact that an unrelated third party indicated that it would preauthorize the services is not relevant to a determination of whether the services were preauthorized by the Carrier in this case. Providers are not able to obtain preauthorization from other carriers, only from the carrier that covers the particular claimant. In this case, Provider made a mistake by submitting the preauthorization request to the wrong carrier and indicating the wrong employer. ___ should not bear the burden of Provider’s mistake.
Provider is not entitled to payment from ___ for the services provided to Claimant.
III. FINDINGS OF FACT
- Claimant, an injured worker, suffered a compensable injury on _____.
- Hill County Healthcare (Provider) provided pain management services for eight hours per day on ten dates of service from November 25, 2008 to December 17, 2008.
- To obtain reimbursement for the services provided to Claimant, Provider was required to obtain preauthorization from ___ (___), Claimant’s employer and the self-insured entity that insured Claimant at the time of her injury.
- Provider did not submit a preauthorization request to ___ or to its authorized agent.
- Provider’s preauthorization request indicated that Claimant’s employer was ___.
- ___ did not preauthorize the pain management services.
- Provider did not have proper preauthorization to perform the pain management services.
- Provider filed a request for medical fee dispute resolution with the Texas Department of Insurance, Division of Workers’ Compensation (Division).
- On April 30, 2012, the Division issued its Medical Fee Dispute Resolution Findings and Decision.
- Provider timely requested a hearing at the State Office of Administrative Hearings (SOAH) to contest the Division’s determination.
- On May 11, 2012, the Division issued a Notice of Hearing. The notice informed the parties of the date, time, and location of the hearing, the matters to be considered, the legal authority under which the hearing would be held, and the statutory provisions applicable to the matters to be considered.
- A hearing convened on August 23, 2012, at SOAH’s facilities in Austin, Texas. Provider was represented by Arturo Gonzales. Carrier was represented by its legal counsel, James Loughlin.
XIII. CONCLUSIONS OF LAW
- The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code § 413.031 and Tex. Gov’t Code ch. 2003.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code§§ 2001.051 and 2001.052.
- Provider had the burden of proof in this proceeding.
- To obtain reimbursement from ___, Provider was required to obtain preauthorization from _____ before performing pain management services for Claimant. 28 Tex. Admin. Code §§ 134.600(f) and 134.600(p)(10).
- Provider is not entitled to payment from ____ for the services provided to Claimant on the dates of service in dispute.
ORDER
IT IS ORDERED thatHill Country Healthcare is not entitled to reimbursement from ___.
Signed October 17, 2012.