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Medical Fee Dispute Resolution

Medical Fee Dispute Resolution. Effective June 1, 2012 (for requests received on or after June 1, 2012). The information contained in this presentation is not a substitute for the Texas Labor Code and/or TDI-DWC rules. . Topics. Medical Fee Dispute Resolution (MFDR)

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Medical Fee Dispute Resolution

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  1. Medical Fee Dispute Resolution Effective June 1, 2012 (for requests received on or after June 1, 2012) The information contained in this presentation is not a substitute for the Texas Labor Code and/or TDI-DWC rules.

  2. Topics • Medical Fee Dispute Resolution (MFDR) • Fee Dispute Resolution Request • General Process • Important Changes Effective June 1, 2012 • Contact Information • Questions & Answers

  3. Medical Fee Dispute Resolution Basic information and statutory/rule authority for Medical Fee Dispute Resolution

  4. Medical Fee Dispute • A disagreement over the amount of payment due for health care determined to be medically necessary and appropriatefor treatment of a compensable injury. • The TDI-DWC’s Medical Fee Dispute Resolution(MFDR) section resolves medical fee disputes

  5. MFDR: Law & Rule • Texas Labor Code §413.031 (c) authorizes MFDR to adjudicate the payment given the relevant statutory provisions and commissioner rules • 28 Texas Administrative Code §133.307 (hereto after referred to as Rule §133.307) sets out the eligibility, filing requirements and general process for adjudication of amedical fee dispute

  6. Filing forMedical Fee Dispute Information to help identify the type of dispute and whether MFDR is the appropriate process

  7. Types of Disputes • The disputes discussed in this presentation relate only to health care that has already been provided, billed, and reduced or denied by the workers’ compensation insurance carrier • Denial of services may result in the following types of disputes: • Compensability, Extent of Injury & Liability Disputes • Medical Necessity Disputes • Medical Fee Disputes • Each dispute type is resolved by a different TDI-DWC section/program area with independent processes

  8. Identifying the Type of Dispute • Carefully read the explanation of benefits (EOB) and other correspondence issued by the workers’ compensation insurance carrier • Match the reduction or denial code to a dispute type • Be aware that you may be required to take certain actions before filing a dispute (such as appeal/reconsideration) • File your dispute in accordance with the appropriate process

  9. Identifying the Type of Dispute(Continued)

  10. Filing for Medical Fee Dispute Resolution • Deadline • Must be filed not later than one year after the date(s) of service in dispute, with few exceptions • Request & Instructions • Form DWC-060, Medical Fee Dispute Resolution Request • Required Documentation • Varies by requestor type • Requestor Types • Health Care Providers • Injured Employees (including first responders) • Pharmacy Processing Agents (PPA) • Subclaimants

  11. Form DWC-060 ChangesFor use on or after June 1, 2012 • Required for use by requestors &respondents • No check box to identify subclaimant, PPA or first responder • Extensive form & table of disputed services • Did not include documentation requirements by requestor type • Required for use by all appropriate requestors • Check box added for subclaimant, PPA and first responder • Minimal form and table for ease of use • Includes documentation requirements by requestor type Former DWC-60 New DWC-60

  12. New Form DWC-060

  13. New Form DWC-060

  14. Process The general adjudication process in MFDR

  15. General Process

  16. Dispute Outcomes - Description • Dismissal • MFDR may dismiss a dispute request for reasons stated by rule • Withdrawal • The requestor may withdraw a dispute at any point after docketing and before a decision is rendered • Decision • MFDR dispute resolution officer may issue a decision with no order, or a decision with an order to pay

  17. Dispute Outcomes - Scenarios

  18. Important Changes Changes effective June 1, 2012

  19. Rule Changes Effective for disputes received in the MFDR section on or after June 1, 2012 • Required info & docs contained in the DWC Form-060 instructions • Language specific to subclaimants, first responder absent • Dismissals are appealable • Decision appeals heard at the TDI-DWC or at SOAH (by dollar amount) • No cost to parties for appeal of dispute decisions to SOAH • Info & docs are required by rule (DWC Form-060 updated) • Language added for subclaimant, first responder • Dismissals are not appealable • Decision appeals go through a BRC, and then may be appealed to SOAH or arbitration • The non-prevailing party at a SOAH is billed for the cost of the proceeding Former Rule §133.307 Effective for disputes received before June 1, 2012 New Rule §133.307 Effective for disputes received on or after June 1, 2012

  20. Dismissal • MFDR may dismiss a fee dispute request received on or after June 1, 2012 for reasons stated in new Rule §133.307 • The reasons for dismissal are communicated in writing to the requestor • The requestor may correct the reasons for dismissal and file a new dispute • A “corrected” request is considered a new request subject to all the requirements of Rule §133.307, including timeliness • A dismissal may not be appealed

  21. Reasons for Dismissals • Examples of disputes that may be dismissed include, but are not limited to: • Requests where the services in dispute have not gone through appeal/reconsideration under 28 Texas Administrative Code §133.250 • Requests containing unresolved issues of compensability, extent or liability • Requests containing unresolved issues of medical necessity • Requests that do not contain the documentation required by Rule §133.307

  22. Appeal of MFDR Decision • Either party has the right to seek review (appeal) of a decision issued by the TDI-DWC’s MFDR section • A party seeking review of an MFDR decision must request a Benefit Review Conference (BRC) no later than 20 days from the date the MFDR decision is received by the party • If the medical fee dispute remains unresolved after the conclusion of a BRC, the parties may request arbitration or a hearing at the State Office of Administrative Hearings(SOAH) no later than 20 days from the conclusion of the BRC • If the dispute remains unresolved at the conclusion of the SOAH hearing, the parties may request judicial review not later than the 45th day after the date on which SOAH mailed the party the notification of the decision

  23. The date the dispute isreceived in the MFDR section is what determines whether the former rule, or the new rule is in effect for the adjudication of the dispute & the appeal of a dispute decision.

  24. Billing of the Non-Prevailing Party • This provision was enacted under House Bill 2605 • Except as otherwise provided by Texas Labor Code §413.0312, the non-prevailing party shall reimburse the TDI-DWC for the costs of services provided by SOAH • If the injured employee is the non-prevailing party, the insurance carrier shall reimburse the TDI-DWC for the costs for services provided by SOAH • In the event of a dismissal, the party requesting the SOAH hearing is billed for the costs

  25. Questions & Answers Common Inquiries

  26. Are untimely filed disputes dismissed? • A determination that a dispute was not timely filed is an appealable decision. No

  27. Are requestors notified of the reasons for dismissal? • Requestors are notified in writing of the reasons that a dispute is being dismissed. Yes

  28. Are there timeframes for the adjudication of disputes? • There are no statutory provisions or rule provisions that impose a timeframe. No

  29. Can a health care provider, subclaimant, or PPA submit a medical fee dispute by fax? • Requests by these specific parties must be submitted via mail service or personal delivery. No

  30. Can an injured employee submit a medical fee dispute by fax? • Injured employees are permitted by rule to fax their requests for dispute resolution. Yes

  31. Is the “loser pay” provision applicable to all decisions rendered on or after June 1, 2012? • “Loser Pay” does not apply to decisions rendered for disputes received in the division’s MFDR section prior to June 1, 2012. No

  32. Is the total cost of a SOAH hearing determined by the TDI-DWC? • The total cost of a contested case hearing at SOAH is determined by SOAH. No

  33. Is the non-prevailing party identified by the TDI-DWC? • The cost of the hearing and identity of non-prevailing party is communicated through the SOAH decision. No

  34. Resources

  35. General Inquiries (not specific to a dispute)

  36. Inquiries on Active/Closed Disputes Contact Information • Telephone number:  (512) 804-4812 • Fax number:  (512) 804-4811 • Address:  7551 Metro Center Drive Suite 100 Austin, TX 78744 • E-Mail: MDRInquiry@tdi.texas.gov WEB Page • http://www.tdi.texas.gov/wc/mfdr/index.html

  37. Other DWC Helpful Links • DWC Home Page http://www.tdi.texas.gov/wc/indexwc.html • History of House Bill 2605/ New 413.0312 http://www.legis.state.tx.us/BillLookup/History.aspx?LegSess=82R&Bill=HB2605 • Texas Labor Code http://www.tdi.texas.gov/wc/act/index.html#act82 • TDI-DWC Rules http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=3&ti=28&pt=2 • Contact TDI-DWC http://www.tdi.texas.gov/wc/dwccontacts.html • Training http://www.tdi.texas.gov/wc/events/index.html

  38. Thank you! Martha Luevano – Manager Greg Arendt – Team Lead Mary Landrum - Director

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