Texas Adopts New Dispute Resolution Procedures For Medical Necessity And Medical Fee Disputes


Austin, TX (WorkersCompenation.com) - The Commissioner of Workers' Compensation Rod Bordelon has adopted amendments to 28 Texas Administrative Code (TAC) §133.307 regarding medical fee dispute resolution; 28 TAC §133.308 regarding medical dispute resolution by independent review organizations; and 28 TAC Chapter 144 regarding medical dispute resolution and arbitration in order to implement portions of House Bill 2605 enacted by the 82nd Legislature, Regular Session, effective September 1, 2011. These adopted amendments affect medical fee and medical necessity disputes that are filed with the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) on or after June 1, 2012.

For medical fee disputes, there is now one appeal process regardless of the amount of reimbursement sought. The appealing party is required to mediate the medical fee dispute at a benefit review conference (BRC) under Texas Labor Code Chapter 410, Subchapter B. If the dispute remains unresolved after a BRC, the parties may elect to engage in binding arbitration as provided by Texas Labor Code §413.0312(d) and under Chapter 410, Subchapter C. If arbitration is not elected, the party is entitled to a contested case hearing (CCH) at the State Office of Administrative Hearings (SOAH). A party who has exhausted all administrative remedies and that disagrees with the final decision of SOAH may seek judicial review of the decision. The non-prevailing party must reimburse the TDI-DWC for the costs for services provided by the SOAH, except as otherwise provided by Texas Labor Code §413.0312. A party that disagrees with the final decision of the TDI-DWC hearing officer may seek judicial review of the decision.

Regarding medical necessity disputes, all disputes, including spinal surgery and certified workers' compensation health care network (network) claims, are entitled to a CCH conducted by the TDI-DWC after review by an independent review organization (IRO). In cases involving health care provided by a network or a political subdivision or pool that provides medical benefits under Texas Labor Code §504.053(b)(2), the hearing officer conducting the hearing shall consider evidence-based treatment guidelines adopted by the network, political subdivision or pool.

The adopted amendments were filed with the Office of the Secretary of State on May 11, 2012 for publication in the May 25, 2012 issue of the Texas Register.

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