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Advisory 98-01

Medical Dispute Resolution Requests Related to Invalidation of 1992 Acute Care Inpatient Hospital Fee Guideline

The Commission provides this information related to hospital reimbursement for which medical dispute resolution is requested for services reimbursed pursuant to the 1992 Acute Care Inpatient Hospital Fee Guideline (formerly §134.400). These requests will be referred to as "hospital disputes."

The following table specifies dates of service and filing deadlines for hospital disputes:
DATES OF SERVICE FILING DEADLINE
September 1, 1992 through February 13, 1997 August 15, 1998
February 14, 1997 through July 31, 1997 Commission rule §133.305 applies - one year from date of service

FIRST NOTE: Any requests for hospital disputes based on "reasonable medical justification," as specified in Texas Labor Code §413.031(b), must have been timely presented within one year from date of service as required by Commission rule §133.305.

SECOND NOTE: For dates of service from August 1, 1997, to the present, Commission rule §134.401 - Acute Care Inpatient Hospital Fee Guideline, effective August 1, 1997, applies.

The Commission strongly encourages all hospitals and insurance carriers to attempt resolution of these hospital disputes. If any party to a hospital dispute needs assistance or information concerning informal resolution services, please contact the Commission's Informal Resolution Conference staff in writing no later than June 30, 1998, at the following address:

Texas Workers' Compensation Commission
Medical Dispute Resolution Section, MS-48
Attention: Steve Nichols - Informal Resolution - Hospital Dispute 4000 South IH-35, Southfield Building
Austin, Texas 78704-7491

In addition, parties are requested to notify the Commission in writing of any hospital disputes that have been settled since filing for dispute resolution. This information should identify the Commission number (TWCC claim #) as well as the assigned Medical Dispute Resolution (MDR) tracking number for the appropriate hospital dispute to be withdrawn from the Commission's docket (see attached form for withdrawing a hospital dispute).

To expedite the decisions on hospital disputes which can be resolved on a basis other than the appropriateness of amount of reimbursement paid to a hospital, the Commission requests submission of the following information:

* reimbursement denials due to lack of compensable injury;

* reimbursement denials due to lack of preauthorization under Commission rule §134.600; and

* copy of contractual agreements between any parties to the hospital dispute relating to payment for the hospital services in dispute.

For hospital disputes already filed with the Commission, this documentation must be received by the Commission by 5:00 p.m., May 15, 1998. For hospital disputes not already filed with the Commission, this same documentation must be submitted when the dispute is filed.

The Commission's Medical Dispute Resolution Section has indicated that parties filing a hospital dispute have the burden of proof to support their position for either advocating additional reimbursement or for requesting refunds. For hospital disputes already filed with the Commission, all evidence a party wishes to have considered must be received by the Commission no later than 5:00 p.m., June 30, 1998. For hospital disputes not already filed with the Commission, evidence must be included with the dispute request. The burden of proof includes production of sufficient evidence to support that the reimbursement requested is in accordance with the factors listed in §413.011(b) of the Texas Workers' Compensation Act (i.e. that the request will result in reimbursement which (1) is fair and reasonable, (2) is designed to ensure the quality of medical care, (3) is designed to achieve effective medical cost control, (4) does not provide for payment of a fee in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual's behalf, and (5) considers the increased security of payment afforded by the Texas Workers' Compensation Act in establishing the fee guidelines.) Resubmitted hospital bills without such evidence may not be considered sufficient evidence to support a decision for changing previous reimbursement. In addition, requests for refunds without such evidence, may not be considered sufficient to support a decision for a refund.

The Commission's Medical Dispute Resolution Section has indicated that, evidence related to what the hospital charged and was paid for similar treatment of an injured individual of an equivalent standard of living will be important in the review of the hospital dispute. In addition, the Commission's Medical Dispute Resolution Section may also utilize reliable information available to the public and take official notice of such information in evaluating evidence submitted by the parties to the hospital dispute.

Any possible violations of the Texas Labor Code identified during the Commission's review of hospital disputes will be referred to the Commission's Compliance and Practices Division for further investigation and appropriate action.

The Commission may issue additional information in the future regarding hospital disputes which are not resolved.

Please direct any questions concerning these matters to the Commission's Medical Dispute

Resolution staff at 512-440-3841.

Signed on this 17th day of February, 1998

Robert M. Marquette
Acting Executive Director

Distribution:
Austin Carrier Representatives
TWCC Staff
Public Information List
Medical Advisory Committee Members
Texas Hospital Association


Date:

Texas Workers' Compensation Commission
Medical Dispute Resolution Section, MS-48
Southfield Building
4000 S. IH-35
Austin, Texas 78704-7491

Dear Commission:

On behalf of___(Name / Location of hospital)____ , I am requesting the following disputes to be withdrawn from the Commission's docket. I understand that no further action will be taken by the Commission on this/these hospital disputes.

Sincerely,

 

Signature
Printed name & title of person signing)

CLAIMANT NAME

TWCC #

MDR TRACKING #

      
     

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