Texas Department of Insurance Division of Workers Compensation

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Texas Department of Insurance Division of Workers\' Compensation. What standards apply to Medical Dispute Resolution?

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Therapeutic Fee Dispute Resolution Effective June 1, 2012 (for solicitations got on or after June 1, 2012) The data contained in this introduction is not a substitute for the Texas Labor Code as well as TDI-DWC rules.

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Topics 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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Medical Fee Dispute Resolution Basic data and statutory/manage specialist for Medical Fee Dispute Resolution

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Medical Fee Dispute A difference over the measure of installment due for social insurance resolved to be therapeutically vital and proper for treatment of a compensable damage . The TDI-DWC's Medical Fee Dispute Resolution(MFDR) segment settle therapeutic expense question

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MFDR: Law & Rule Texas Labor Code §413.031 (c) approves MFDR to mediate the installment given the pertinent statutory arrangements and magistrate rules 28 Texas Administrative Code §133.307 (hereto after alluded to as Rule §133.307) sets out the qualification, recording prerequisites and general process for arbitration of a restorative charge debate

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Filing for Medical Fee Dispute Information to help distinguish the sort of question and whether MFDR is the proper procedure

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Types of Disputes The debate examined in this introduction relate just to human services that has as of now been given, charged, and diminished or denied by the specialists' pay protection bearer Denial of administrations may bring about the accompanying sorts of question: Compensability, Extent of Injury & Liability Disputes Medical Necessity Disputes Medical Fee Disputes Each debate sort is settled by an alternate TDI-DWC segment/program region with autonomous procedures

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Identifying the Type of Dispute Carefully read the clarification of advantages (EOB) and other correspondence issued by the laborers' pay protection transporter Match the decrease or disavowal code to a question sort Be mindful that you might be required to take certain activities before recording a debate, (for example, offer/reevaluation) File your debate as per the fitting procedure

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Identifying the Type of Dispute (Continued)

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Filing for Medical Fee Dispute Resolution Deadline Must be documented not later than one year after the date(s) of administration in debate, with couple of exemptions Request & Instructions Form DWC-060, Medical Fee Dispute Resolution Request Required Documentation Varies by requestor sort Requestor Types Health Care Providers Injured Employees (counting people on call) Pharmacy Processing Agents (PPA) Subclaimants

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Form DWC-060 Changes For use on or after June 1, 2012 Required for use by requestors &respondents No check box to recognize subclaimant , PPA or person on call Extensive shape & table of debated administrations Did exclude documentation necessities by requestor sort Required for use by all suitable requestors Check box included for subclaimant , PPA and specialist on call Minimal frame and table for usability Includes documentation prerequisites by requestor sort Former DWC-60 New DWC-60

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New Form DWC-060

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New Form DWC-060

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Process The general settling process in MFDR

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General Process

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Dispute Outcomes - Description Dismissal MFDR may reject a question ask for reasons expressed by administer Withdrawal The requestor may pull back a debate anytime subsequent to docketing and before a choice is rendered Decision MFDR question determination officer may issue a choice with no request, or a choice with a request to pay

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Dispute Outcomes - Scenarios

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Important Changes powerful June 1, 2012

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Rule Changes Effective for question got in the MFDR segment on or after June 1, 2012 Required data & docs contained in the DWC Form-060 guidelines Language particular to subclaimants , person on call truant Dismissals are appealable Decision advances heard at the TDI-DWC or at SOAH (by dollar sum) No cost to parties for interest of question choices to SOAH Info & docs are required by control (DWC Form-060 refreshed) Language included for subclaimant, specialist on call Dismissals are not appealable Decision advances experience a BRC, and afterward might be spoke to SOAH or intervention The non-winning gathering at a SOAH is charged for the cost of the procedure Former Rule §133.307 Effective for question got before June 1, 2012 New Rule §133.307 Effective for question got on or after June 1, 2012

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Dismissal MFDR may expel an expense question ask for got on or after June 1, 2012 for reasons expressed in new Rule §133.307 The explanations behind expulsion are imparted in writing to the requestor The requestor may adjust the purposes behind expulsion and document another debate An "amended" demand is viewed as another demand subject to every one of the prerequisites of Rule §133.307, including auspiciousness An expulsion may not be claimed

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Reasons for Dismissals Examples of debate that might be expelled incorporate, yet are not restricted to: Requests where the administrations in question have not experienced interest/reexamination under 28 Texas Administrative Code § 133.250 Requests containing uncertain issues of compensability, degree or risk Requests containing uncertain issues of medicinal need Requests that don't contain the documentation required by Rule §133.307

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Appeal of MFDR Decision Either party has the privilege to look for audit (advance) of a choice issued by the TDI-DWC's MFDR area A gathering looking for survey of a MFDR choice must demand a Benefit Review Conference (BRC) no later than 20 days from the date the MFDR choice is gotten by the gathering If the therapeutic expense debate stays uncertain after the determination of a BRC, the gatherings may ask for assertion or a hearing at the State Office of Administrative Hearings(SOAH) no later than 20 days from the finish of the BRC If the debate stays uncertain at the finish of the SOAH hearing, the gatherings may ask for legal audit not later than the 45 th day after the date on which SOAH sent the gathering the warning of the choice

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The date the debate is gotten in the MFDR segment is the thing that figures out if the previous govern, or the new manage is in actuality for the settling of the question & the interest of a debate choice.

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Billing of the Non-Prevailing Party This arrangement was authorized under House Bill 2605 Except as generally given by Texas Labor Code §413.0312, the non-winning gathering might repay the TDI-DWC for the expenses of administrations gave by SOAH If the harmed worker is the non-winning gathering, the protection transporter should repay the TDI-DWC for the expenses for administrations gave by SOAH in case of a rejection, the gathering asking for the SOAH hearing is charged for the expenses

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Questions & Answers Common Inquiries

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Are less than ideal documented debate expelled? An assurance that a question was not convenient recorded is an appealable choice. No

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Are requestors informed of the purposes behind rejection? Requestors are informed in composing of the reasons that a debate is being expelled. Yes

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Are there time allotments for the arbitration of question? There are no statutory arrangements or decide arrangements that force a time allotment. No

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Can a social insurance supplier, subclaimant, or PPA present a therapeutic charge debate by fax? Asks for by these particular gatherings must be submitted by means of mail administration or individual conveyance. No

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Can a harmed worker present a restorative expense debate by fax? Harmed representatives are allowed by run to fax their solicitations for debate determination. Yes

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Is the "failure pay" arrangement appropriate to all choices rendered on or after June 1, 2012? "Washout Pay" does not have any significant bearing to d ecisions rendered for question got in the division's MFDR segment preceding June 1, 2012. No

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Is the aggregate cost of a SOAH hearing dictated by the TDI-DWC? The aggregate cost of a challenged case hearing at SOAH is dictated by SOAH. No

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Is the non-winning gathering recognized by the TDI-DWC? The cost of the hearing and character of non-winning gathering is conveyed through the SOAH choice. No

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General Inquiries (not particular to a question)

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Inquiries on Active/Closed Disputes Contact Information Telephone number:  (512) 804-4812 Fax number:  (512) 804-4811 Address:  7551 Metro Center Drive Suite 100 Austin, TX 78744 E-Mail: MDRInquiry@tdi.texas.gov WEB Page http://www.tdi.texas.gov/wc/mfdr/index.html

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Other DWC Helpful Links 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/bar/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/occasions/index.html

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Thank you! Martha Luevano – Manager Greg Arendt – Team Lead Mary Landrum - Director