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Texas Department of Insurance
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Disputes about medical treatment - medical fees

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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).

Need help?

  • Call DWC Customer Service at 800-252-7031, Monday through Friday, 8 a.m. to 5 p.m., Central time;
  • The Office of Injured Employee Counsel (OIEC) is a state agency that offers injured employees free help with workers’ compensation claims. If you do not have an attorney and want help from an ombudsman, contact OIEC at 866-393-6432, ext. 44186;
  • If you want an attorney and need help finding one, contact the State Bar of Texas at 800-252-9690.

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-045MRequest 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:
      Texas Department of Insurance, Division of Workers’ Compensation
      Hearings, Mail Code HRG
      PO Box 12050
      Austin, TX 78711-2050
    • 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 arbitration or for a hearing to appeal the decision. If a party asks for a hearing, it will be held before the State Office of Administrative Hearings (SOAH) in Austin, Texas.

If you want a SOAH hearing:

  • File your request no later than 20 days after the BRC is over.
  • Make your request in writing and follow the instructions on the DWC Form-49Request to Schedule a Medical Contested Case Hearing (MCCH).
  • Send a copy of the request to the DWC Chief Clerk of Proceedings by:
    • Mail:
      Texas Department of Insurance, Division of Workers’ Compensation
      Hearings, Mail Code HRG
      PO Box 12050
      Austin, TX 78711-2050
    • Fax: 512-804-4011
  • Send a copy of your request to the other parties.

To learn more about requesting arbitration or requesting a hearing with SOAH, see 28 TAC §133.307(g)(2)(A).

What will happen after a hearing is requested?

SOAH will send you notice of the date and time for the hearing that will be held in Austin. Learn more about SOAH hearings in 28 TAC §133.307(g) and Chapter 148.

At the hearing, the SOAH judge will consider evidence offered by the parties about the medical fee dispute. The SOAH judge will not consider other issues, such as liability, extent, compensability, or medical necessity about the fee dispute. After the SOAH hearing, the judge will make a decision that will be sent to the parties.

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 the decision.

To learn more about judicial review of a medical fee dispute, see Texas Labor Code §413.031(k-1) and 28 TAC §133.307(g)(3).

Who pays for the costs of services provided by SOAH?

Generally, the party that does not win at SOAH pays. If the injured employee does not win, the insurance carrier pays.

Learn more about the costs associated with a SOAH hearing at 28 TAC §133.307(h) and Labor Code §413.0312

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Last updated: 9/13/2023