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At a Glance:
Title:
454-15-3738-m4-np
Date:
July 13, 2016

454-15-3738-m4-np

July 13, 2016

DECISION AND ORDER

Texas Mutual Insurance Company (TMIC) challenges a decision of the Texas Department of Insurance, Division of Workers’ Compensation (Division) holding that TMIC is liable for a medical bill from J. Thomas Dilger, Jr., M.D., associated with the treatment of an injured worker. On April 22, 2016, TMIC filed a Motion for Summary Disposition with the State Office of Administrative Hearings. In the motion, TMIC asserted that Dr. Dilger failed to send it the bill and, instead, erroneously sent it to another carrier. Consequently, TMIC was unaware that Dr. Dilger had provided services to a covered worker and sought reimbursement for them until it received a Medical Fee Dispute Resolution Decision from the Division ordering it to reimburse Dr. Dilger. Because of Dr. Dilger’s failure, TMIC argued, he did not to comply with various Division rules pertaining to the medical fee reimbursement process and was not entitled to reimbursement. Dr. Dilger did not reply to the Motion for Summary Disposition.

On May 18, 2016, the Administrative Law Judge (ALJ) issued an order granting the Motion for Summary Disposition, cancelling the hearing that was set for June 8, 2016, and informing the parties that a Decision and Order consistent with the ruling would follow. As reflected in the Findings of Fact and Conclusions of Law, this Decision and Order confirms the ALJ’s May 18, 2016 ruling granting the Motion for Summary Disposition and finding that Dr. Dilger is not entitled to reimbursement from TMIC.

I.FINDINGS OF FACT

  1. On November 26, 2012, J. Thomas Dilger, Jr., M.D., provided medical services to an injured worker.
  2. Dr. Dilger mistakenly sent a claim for reimbursement for his services to Valley Forge Insurance Company, a carrier that was not liable on the claim.
  3. Texas Mutual Insurance Company (TMIC) was the workers’ compensation insurer for the injured worker’s employer.
  4. Dr. Dilger never served TMIC with a claim for reimbursement associated with the November 26, 2012 medical services.
  5. The Texas Department of Insurance, Division of Workers’ Compensation (Division) did not provide TMIC with a copy of Dr. Dilger’s request for medical fee dispute resolution and associated documentation.
  6. TMIC first became aware of the injured worker, Dr. Dilger’s November 26, 2012 services, and the bill for his services when the Division issued its Medical Fee Dispute Resolution Findings and Decision on December 19, 2014.

VI.CONCLUSIONS OF LAW

  1. The State Office of Administrative Hearings (SOAH) has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Texas Labor Code § 413.0312 and Texas Government Code ch. 2003.
  2. Dr. Dilger did not comply with the requirements of 28 Texas Administrative Code § 133.20(a) because he failed to submit to TMIC all medical bills associated with his November 26, 2012 medical services.
  3. Dr. Dilger did not comply with the requirements of 28 Texas Administrative Code § 133.20(b) because he failed to submit his medical bill to TMIC no later than the 95th day after the date the services were provided.
  4. The Division’s rules, at 28 Texas Administrative Code § 133.307.c)(5), provide that the Division will forward to the carrier a copy of the request for medical fee dispute resolution and associated documentation.
  5. TMIC never had the opportunity to consider and take final action on Dr. Dilger’s bill for the November 26, 2012 medical services.
  6. TMIC did not have an opportunity to participate in the Division’s dispute resolution process.
  7. TMIC is not liable for the fees associated with Dr. Dilger’s November 26, 2012 medical services.
  8. ORDER

IT IS ORDERED that J. Thomas Dilger, Jr., M.D., is not entitled to any reimbursement from Texas Mutual Insurance Company for the services provided to the injured worker on November 26, 2014.

NONPREVAILING PARTY DETERMINATION

Texas Labor Code § 413.0312(g) and 28 Texas Administrative Code § 133.307(h) require the nonprevailing party to reimburse the Division for the cost of services provided by SOAH. Texas Labor Code § 413.0312(i) requires that SOAH identify the nonprevailing party and any costs for services provided by SOAH in its final decision. For purposes of Texas Labor Code § 413.0312, J. Thomas Dilger, Jr., M.D., is the nonprevailing party. The costs associated with this decision are set forth in Attachment A to this Decision and Order and are incorporated herein for all purposes.

Signed July 13, 2016.

End of Document
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