Effective June 1, 2012 (for requests received on or after June 1, 2012) 1 The information contained in this presentation is not a substitute for the Texas.

Effective June 1, 2012(for requests received on or after June 1, 2012)

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The information contained in this presentation is not a substitute for the Texas Labor Code and/or TDI-DWC rules.

‣Medical Fee Dispute Resolution (MFDR)

‣Fee Dispute Resolution Request

‣General Process

‣Important Changes Effective June 1, 2012

‣Contact Information

‣Questions & Answers

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

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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

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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

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Information to help identify the type of dispute and whether MFDR is the appropriate process

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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

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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

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EOB Code Examples (not an exhaustive list) Dispute Type Resolved By

Link to Resources and Requirements

Reduced or denied dueto compensability, extent of injury, or

liability

Compensability, Extent of Injury or

Liability

TDI-DWCHEARINGSSECTION

http://www.tdi.texas.gov/wc/idr/brcinfo.html

Services are not medically necessary; services reduced or denied due to Peer

Review

Medical Necessity Dispute

Managed Care Quality Assurance

(MCQA) 

http://www.tdi.texas.gov/hmo/iro_requests.html

Services reduced according to Texas fee

guidelines; exceed authorization or

authorization required

Medical Fee Dispute

Medical Fee Dispute Resolution (MFDR)

http://www.tdi.texas.gov/wc/mfdr/index.html

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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

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Former DWC-60 New DWC-60

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

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New Form DWC-060New Form DWC-060

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New Form DWC-060New Form DWC-060

The general adjudication process in MFDR

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General ProcessGeneral Process

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

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Scenarios Decision

Dismissal

Withdrawal

Notice to the Respondent Yes No Yes

May be appealed by the parties Yes No No

Posted to the web (redacted) Yes No No

Parties may request amendments/clerical corrections

Yes No No

Re-submit as a new fee dispute No Yes Yes

Changes effective June 1, 2012

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Former Rule §133.307Effective for disputes received before June 1, 2012

New Rule §133.307Effective for disputes received 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

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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

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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

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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

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

Date received in MFDR section

Applicable Rule

Date Decision Received by Parties

Date Party Submits Appeal Request

Appeal Loser pays SOAH costs

May 1, 2008 Former §133.307

Jun 1, 2012 Jun 20, 2012 CCH at DWC or SOAH (former rule)

No

Mar 7, 2010 Former §133.307

Jun 30, 2012 Jul 3, 2012 CCH at DWC or SOAH (former rule)

No

May 31, 2012

Former §133.307

Jul 26, 2012 Aug 15, 2012 CCH at DWC or SOAH (former rule)

No

Jun 1, 2012 New §133.307

Jul 26, 2012 Aug 15, 2012 BRC, then SOAH (new rule)

Yes

Jun 15, 2012 New §133.307

Jul 26, 2012 Aug 3, 2012 BRC, then SOAH (new rule)

Yes

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

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Common Inquiries

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Are untimely filed disputes dismissed?

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A determination that a dispute was not timely filed is an appealable decision.

Are requestors notified of the reasons for dismissal?

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Requestors are notified in writing of the reasons that a dispute is being dismissed.

Are there timeframes for the adjudication of disputes?

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There are no statutory provisions or rule provisions that impose a timeframe.

Can a health care provider, subclaimant, or PPA submit a medical fee dispute by fax?

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Requests by these specific parties must be submitted via mail service or personal delivery.

Can an injured employee submit a medical fee dispute by fax?

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Injured employees are permitted by rule to fax their requests for dispute resolution.

Is the “loser pay” provision applicable to all decisions rendered on or after June 1, 2012?

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“Loser Pay” does not apply to decisions rendered for disputes received in the division’s MFDR section prior to June 1, 2012.

Is the total cost of a SOAH hearing determined by the TDI-DWC?

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The total cost of a contested case hearing at SOAH is determined by SOAH.

Is the non-prevailing party identified by the TDI-DWC?

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The cost of the hearing and identity of non-prevailing party is communicated through the SOAH decision.

Resources

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General Inquiries (not specific to a dispute)

Contact Information◦ Telephone number:  (512) 804-4812 ◦ Fax number:  (512) 804-4811 ◦ Address: 

7551 Metro Center Drive Suite 100 Austin, TX 78744

◦ E-Mail:[email protected]

WEB Page◦ http://www.tdi.texas.gov/wc/mfdr/index.html

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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

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