noting that under Medical Fee Guideline 1996 promulgated by the Division, any party not satisfied with the Division’s decision on proper payment of claim "may continue the review process through [the State Office of Administrative Hearings] and then the courts"
How later courts described this case
- noting that under Medical Fee Guideline 1996 promulgated by the Division, any party not satisfied with the Division’s decision on proper payment of claim "may continue the review process through [the State Office of Administrative Hearings] and then the courts"
- holding no due-process violation when there was “no evidence presented to show that [agency] rules . . . prevent[ed] [a party] from taking advantage of these defined procedures to challenge the reimbursement amounts paid for medical services.”
- considering whether Texas Worker’s Compensation Commission’s dispute and audit rules constituted improper delegation of its authority to private entities
- describing former Rule 133.304(m) in only these terms: “A health care provider that disagrees with a carrier’s determination of the reimbursement amount may initiate the dispute resolution process.”
Written by the judges who cited it.
The opinion
Justice SMITH,
concurring.
The Court concludes that “a private insurance carrier’s act of reviewing medical bills and determining a reimbursement amount when no MAR has been established [does not fall] within the legal definition of a delegation.” 136 S.W.3d at 657. I agree but write separately to express my understanding that the carrier’s reimbursement determination does not constitute an administrative rule and that a de novo determination of the “fair and reasonable” reimbursement rate 1 will be made in both the TWCC medical service review 2 and the SOAH contested-case hearing 3 without deference to the carrier’s previous reimbursement determination.
.See 28 Tex. Admin. Code § 134.1 (c) (2004)("Reimbursement for services not identified in an established fee guideline shall be reimbursed at fair and reasonable rates as described in the Texas Workers’ Compensation Act, § 413.011 until such period that specific fee guidelines are established by the commission.”).
. See generally Tex. Lab.Code § 413.031.
. See Tex. Lab.Code § 413.031(k).