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Title:
454-16-2156-m4-np
Date:
June 10, 2016

454-16-2156-m4-np

June 10, 2016

DECISION AND ORDER

______ (Carrier) challenges a decision of the Texas Department of Insurance, Division of Worker’s Compensation that awarded Healthtrust full reimbursement for a chronic pain management program. In support of its assertion that Healthtrust is not entitled to $2,012.50 of the amount billed, ___ (carrier) argues that the program’s afternoon sessions were not adequately documented. Healthtrust argues that its employees stake their licenses on representations made regarding services provided, and that the documentation of every minute of services provided in a group setting is not possible. As reflected in the Findings of Fact and Conclusion of Law, ___ (Carrier) proved that Healthtrust is not entitled to additional reimbursement.

I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There are no issues of notice or jurisdiction. Therefore, these matters are addressed in the Findings of Fact and Conclusions of Law without further discussion.

I.FINDINGS OF FACT

  1. ___ (Carrier) challenges a medical fee dispute resolution decision of the Texas Department of Insurance, Division of Worker’s Compensation that awarded Healthtrust additional reimbursement of $2,012.50 for a chronic pain management program provided during an 8-day period from January 31, 2012, through February 9, 2012.
  2. ___ (Carrier) timely requested a hearing before the State Office of Administrative Hearings (SOAH) to contest the decision.
  3. On February 2, 2016, the Division issued a Notice of Hearing to the parties. 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.
  4. A hearing convened and closed before Administrative Law Judge Gary Elkins on April 25, 2016, at SOAH’s facilities in Austin, Texas. __ (Carrier) appeared and was represented by attorney J. Red Tripp. Healthtrust appeared and was represented by its office administrator, Tony Chapman.
  5. Healthtrust’s record of services provided during the following sessions of chronic pain management did not add up to 8 hours each day. The following table reflects the dates of service, the hours documented by Healthtrust, and the hours reimbursed by (Carrier):
  6. Healthtrust billed (Carrier) for 8 hours on each of the 8 dates of service listed in Finding of Fact No. 5.
  7. Healthtrust failed to account for 8 hours of chronic pain management services on each of the 8 dates of service billed to___(Carrier).
  8. Healthtrust’s claim for additional reimbursement is not supported by the medical documentation associated with the disputed services.

X. CONCLUSIONS OF LAW

  1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Texas Labor Code § 413.0312 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. Healthtrust’s medical documentation for the services provided during the afternoons of its chronic pain management program did not substantiate the amount of care for which it sought reimbursement, as required by 28 Texas Administrative Code § 133.210.
  4. Healthtrust is not entitled to additional reimbursement for the chronic pain management program.

Date of Service

Hours Documented

Hours Reimbursed

January 31, 2012

5.92

6.50

February 1, 2012

5.66

6.75

February 2, 2012

6.17

6.75

February 3, 2012

6.58

7.00

February 6, 2012

6.10

6.50

February 7, 2012

5.66

6.00

February 8, 2012

6.50

6.50

February 9, 2012

6.17

7.00

ORDER

IT IS ORDERED that Healthtrust is not entitled to additional reimbursement in the amount of $2,012.50 for the chronic pain management program provided to the injured worker.

Signed June 10, 2016.

End of Document
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