DECISION AND ORDER

Facility Insurance Corporation (Carrier) challenges the order granting additional reimbursement to Patients Medical Center (Provider) for services provided to an injured worker. The Administrative Law Judge (ALJ) concludes that Provider is entitled to additional reimbursement from Carrier for the services provided.

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 March 13, 2013, the Division issued its Medical Fee Dispute Resolution Findings and Decision. On April 2, 2013, Carrier requested a hearing at the State Office of Administrative Hearings (SOAH) to contest the Division’s determination. On May 10, 2013, the Division issued a Notice of Hearing. A hearing convened before ALJ Stephen J. Pacey on July 8, 2013, at SOAH’s facilities in Austin, Texas. Provider was represented by its legal counsel, James G. Gumbert. Carrier was represented by its legal counsel, Steven M. Tipton. The record remained open until August 5, 2013, when Provider’s written closing argument was received by SOAH.

II. DISCUSSION

A.Applicable Law

Section 408.027(a) of the Texas Labor Code (Code) requires a health care provider to “submit a claim for payment to the insurance carrier not later than the 95th day after the date on which the health care services are provided to the injured employee.” Further, failure by the health care provider to timely submit a claim for payment constitutes a forfeiture of the provider’s right to reimbursement for that claim for payment.

Health care providers are required to submit medical bills for payment on standard forms used by Centers for Medicare and Medicaid Services (CMS). All information submitted on required billing forms must be legible and completed in accordance with Division instructions.

The health care provider submits medical bills to the insurance carrier^[1] using correct billing codes from the applicable Division fee guidelines.^[2] Health care providers may correct and resubmit as a new bill an incomplete bill that has been returned by the insurance carrier.^[3] A “complete medical bill” is a medical bill that contains all required fields as set forth in the billing instructions for the appropriate form as specified in the Division’s rules.

B.Relevant Facts

Claimant injured her back while moving a desk. Multiple surgeries ensued, including an L3-S1 fusion. For pain, Claimant previously had a spinal cord stimulator implanted. It worked well, but the leads migrated and it became ineffective. The leads are electrodes that send electric impulses to parts of the spine. Claimant’s doctor requested preauthorization to replace the leads. Acknowledging that there was a generator in place, Carrier approved the preauthorization request. Claimant’s doctor also requested preauthorization to replace the leads by hooking them back up and reprogramming the generator unit. The Carrier concluded that this was a “very reasonable treatment plan” and preauthorized replacement of the pre-existing electrodes and the reprogramming of the generator.

In the operative note,^[4] the treating physician reported that he dissected the generator and the lead from the generator pocket, and then he tunneled the connectors back from the pocket and secured them. The doctor also reported that he placed the generator back in the generator pocket and sutured it shut. Under the doctor’s guidance, reprogramming was performed.

On or about September 30, 2009, Provider sent a bill to Carrier for its services. The amount of the bill was $94,640.48, of which the Carrier paid $2,354.75. On April 19, 2010, Provider sent Carrier another bill to correct some coding errors on the initial bill. When Carrier made no further reimbursement, Provider requested medical fee dispute resolution on September 23, 2010. The Division issued its March 13, 2013 decision awarding Provider an additional $20,495.78. On April 2, 2013, Carrier requested a SOAH hearing.

C.Discussion and Analysis

There are three issues in this case. The first issue is whether the medical bill sent on September 30, 2009, was a complete medical bill as defined by 28 Texas Administrative Code (TAC) § 133.2. The second issue is whether the Carrier had the burden of proof. The third issue is whether the services were preauthorized.

Completeness of Bill

The medical bill sent on September 30, 2009, was a complete medical bills as defined by 28 TAC § 133.2(a)(3). The Division does not define an incomplete medical bill, but it has adopted the Medicare payment policies, which do address it.^[5] The “Medicare Claims Processing Manual” (Medicare Manual) defines “Incomplete Submissions” as “any submission missing required information (e.g., no provider name).”^[6] The Medicare Manual defines “Invalid submissions” as “any submission that contains complete and required information; however, the information is illogical or incorrect (e.g., incorrect HIC#, invalid procedure codes) or does not conform to required claim formats.”^[7] Although Carrier contended the erroneous procedure code caused Provider’s bill to be incomplete, under the Division’s rule, Provider’s initial submission was a complete medical bill that contained an incorrect procedure code. The medical bill Provider sent to Carrier on September 30, 2009, was a complete medical bill as defined by 28 TAC § 133.2(a)(3). Consequently, the Division had authority to consider Provider’s request for additional reimbursement.

Burden of Proof

Notwithstanding Carrier’s arguments to the contrary, the ALJ concludes that the party seeking affirmative relief from the agency decision has the burden of proof. Carrier requested a contested case hearing to challenge the Division’s decision. Provider did not. Carrier has the burden of proof in this case.

Preauthorization

Provider performed a procedure to replace pre-existing electrodes that had migrated. Current Procedural Terminology (CPT) Code 63660 encompasses the revision or removal of spinal neurostimulator electrodes. The evidence leaves no doubt that this procedure involved a pre-existing system requiring a revision. The other procedure performed was the reprogramming of the generator under CPT Code 95972, which is a complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter with intraoperative or subsequent programming. Carrier preauthorized both procedures and Provider performed them.

Conclusion

Facility Insurance Corporation failed to carry its burden of proving that Patients Medical Center was not entitled to $20,495.78 in additional reimbursement. Therefore, Facility Insurance Corporation owes Patients Medical Center $20,495.78 in additional reimbursement, plus any applicable interest.

III. FINDINGS OF FACT

1. On September 23, 2009, services were performed at a Patients Medical Center (Provider) for an injured worker (Claimant).
2. Facility Insurance Corporation (Carrier) was the responsible workers’ compensation insurer for the Claimant.
3. Provider billed Carrier the sum of $94,640.48 for the services it provided to the Claimant.
4. Carrier reimbursed Provider $2,354.75 for the services.
5. Carrier denied Provider’s request for additional reimbursement.
6. Provider timely filed a request for medical fee dispute resolution with the Texas Department of Insurance, Division of Workers’ Compensation (Division).
7. On March 13, 2013, the Division issued its Medical Fee Dispute Resolution Findings and Decision (MDR Decision), ordering Carrier to pay Provider an additional $20,495.78.
8. Carrier timely requested a hearing before the State Office of Administrative Hearings (SOAH) to contest the MDR Decision.
9. A Notice of Hearing 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.
10. On July 8, 2013, a hearing convened before Administrative Law Judge Stephen J. Pacey at SOAH’s facilities in Austin, Texas. Provider was represented by attorney James C. Gumbert. Carrier was represented by attorney Steven M. Tipton. The record closed on August 5, 2013, following the filing of post-hearing briefs.
11. The initial bill, with all fields completed, was received by Carrier within 95 days from the date of service but contained a procedure coding error.
12. The initial bill was complete.
13. On August 24, 2009, Carrier preauthorized both a CPT Code 63660 procedure and a CPT Code 95972 procedure.
14. Under CPT Code 63660, Provider replaced pre-existing electrodes that had migrated. CPT Code 63660 covers the revision or removal of spinal neurostimulator electrodes.
15. The electrodes that were replaced were part of an existing generator system.
16. Provider performed a procedure under CPT Code 95972, to reprogram the existing generator which is a complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter with intraoperative or subsequent programming.

III.CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Texas Labor Code § 413.031 and Texas Government Code. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Texas Government Code§§ 2001.051 and 2001.052.
3. Carrier had the burden of proof in this proceeding.
4. Provider was required to submit a claim for payment to Carrier not later than the 95th day after the date on which the health care services were provided to the injured employee. Texas Labor Code § 408.027(a).
5. The medical bill Provider sent on September 30, 2009, was a complete medical bill as defined by 28 Texas Administrative Code § 133.2.
6. Carrier failed to carry its burden that Provider is not entitled to $20,495.78 in additional reimbursement.
7. Carrier is required to reimburse Provider the additional amount of $20,495.78, plus any applicable interest.

ORDER

IT IS ORDERED that Facility Insurance Corporation pay Patients Medical Center the additional sum of $20,495.78, plus any applicable interest, for the services provided to Claimant.

Signed August 28, 2013.

1. 28 Texas Administrative Code (TAC) § 133.20(a).↑
2. 28 TAC § 133.20(c).↑
3. 28 TAC § 133.20(g).↑
4. Resp. Ex. A at p. 14.↑
5. 28 TAC §§ 134.403(b)(3).↑
6. Medicare Manual at 70.2.3.1. Required information is defined as “any data element that is needed to process the submission (e.g., Provider Name).”↑
7. Medicare Manual at 70.2.3.1.↑