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Title:
454-17-0687-m4-np
Date:
February 13, 2017

454-17-0687-m4-np

February 13, 2017

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 Medspring Urgent Care (Medspring) associated with the treatment of an injured worker. On November 16, 2016, TMIC filed a Motion for Summary Disposition with the State Office of Administrative Hearings. In the motion, TMIC asserted that, because Medspring failed to submit its request for medical fee dispute resolution to the Division within 1 year from the date of service, it waived its right to medical fee dispute resolution. Medspring did not file a response to the motion. On December 16, 2016, the Administrative Law Judge issued an order granting TMIC’s motion for summary disposition. The Decision and Order affirms that ruling. Because its request for dispute resolution was not timely filed, Medspring is not entitled to reimbursement for the services provided. The following Findings of Fact and Conclusions of Law support this conclusion.

I.FINDINGS OF FACT

  1. On March 18, 2015, Medspring Urgent Care (Medspring) provided medical services to an injured worker.
  2. Texas Mutual Insurance Company (TMIC) was the workers’ compensation insurer for the injured worker’s employer.
  3. Following the medical services, Medspring submitted a request for reimbursement to TMIC.
  4. TMIC denied the reimbursement request.
  5. Medspring requested medical fee dispute resolution from the Texas Department of Insurance, Division of Workers’ Compensation (Division), on June 6, 2016.
  6. The Division granted reimbursement to Medspring and ordered TMIC to make reimbursement in the amount of $322.63.
  7. TMIC challenged the Division’s decision by timely requesting a hearing before the State Office of Administrative Hearings (SOAH).
  8. On October 18, 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 factual 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.
  9. On November 16, 2016, TMIC filed motion for summary disposition in which it argued that, because Medspring failed to request medical fee dispute resolution within 1 year from the date of service, it waived its right to medical fee dispute resolution.
  10. Medspring did not reply to the motion for summary disposition.
  11. On December 16, 2016, the Administrative Law Judge issued an order granting the motion for summary disposition and cancelling the hearing before SOAH.

V.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. Both parties received notice of the hearing in accordance with Texas Government Code §§ 2001.051, .052.
  3. Medspring did not comply with the requirements of 28 Texas Administrative Code § 133.307.c)(1) because it failed to request medical fee dispute resolution at the Division within 1 year from the March 18, 2015 date of services.
  4. TMIC is not liable for the fees associated with Medspring’s March 18, 2015 medical services.
  5. ORDER

IT IS ORDERED that Medspring Urgent Care is not entitled to any reimbursement from Texas Mutual Insurance Company for the services provided to the injured worker on March 18, 2015.

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, Medspring Urgent Care 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 February 13, 2017.

End of Document
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