Disputes about medical treatment - medical fees

After your work injury, you may need medical treatment. The insurance carrier pays for your medical treatment that is necessary and related to your work injury. Sometimes there are disputes about the amount of medical fees charged for the health care.

Medical fee disputes

If the parties have a dispute about medical fees, the dispute will go to DWC Medical Fee Dispute Resolution. They will make a decision about the medical fee dispute. 

What if you don’t agree with the medical fee dispute decision?

If a party does not agree with the decision, they may appeal by asking for a benefit review conference (BRC).

What is a BRC for a medical fee dispute?

The BRC is an informal meeting where the parties talk about the medical fee dispute. The claimant, along with their attorney or ombudsman, the medical provider’s representative, the insurance carrier’s representative, and the benefit review officer will be at the BRC.

The benefit review officer will explain the parties’ rights, the procedures, and help the parties:

• talk about the issues, claim information, and facts; and
• work to reach an agreement.

To ask for a BRC about a medical fee dispute:

• Send your request for a BRC to DWC by the 20th day after you get the decision about the medical fee dispute.
• Use DWC Form-045M, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD).
• Follow the directions on the form.
• Include a copy of the medical fee dispute decision.
• Provide the section of DWC’s fee guidelines that relates to your dispute. Learn more about medical fee guidelines.
• If you are an injured employee asking for a BRC, attach receipts for any out-of-pocket expenses you paid.
• Send a copy of the request and documents to DWC by:
  • Mail: 7551 Metro Center Drive, Suite 100, MS-35, Austin, Texas 78744-1645; or
  • Fax: 512-804-4011
• Send a copy to the other parties.

What if you don’t reach an agreement at the BRC?

If there is no agreement, a party may ask for a hearing before the State Office of Administrative Hearings (SOAH) to appeal the decision.

• Request a SOAH hearing no later than 20 days after the BRC is over.
• Make your request in writing, and follow the instructions on the DWC Form-49, Request to Schedule a Medical Contested Case Hearing (MCCH).
• Send a copy of the request to the DWC Chief Clerk of Proceedings by:
  • Mail: 7551 Metro Center Drive, Suite 100, MS-35, Austin, Texas 78744-1645; or
  • Fax: 512-804-4011
• Send a copy of your request to the other parties.

To learn more about requesting a hearing with SOAH, see 28 Texas Administrative Code §133.307(g)(2)(A).

What if you don’t agree with the SOAH decision?

If a party disagrees with the SOAH decision, they can ask for judicial review of that decision.

Learn more about:

• Medical fee dispute resolution before a BRC
• Fee guidelines and information
• About BRCs
• Sending information
• How to attend a BRC
• Medical Fee Dispute Resolution decisions
• Medical dispute resolution rules
  • 28 Texas Administrative Code (TAC) § 133.305 - General
  • 28 TAC § 133.307 - MDR of Fee Disputes