Texas Department of Insurance

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Texas Department of Insurance Division of
Workers Compensation Medical Fee Dispute
Resolution (MFDR) Mary Landrum
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Medical Fee Dispute Resolution Overview
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What rules apply to Medical Dispute Resolution?
133.305 General Provisions 133.307
Resolution of Non-Network Medical Fee
Disputes 133.308 Resolution by Independent
Review Organization (both non-
network and network)
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Are all disputes handled at the same place?

• No, there are three separate and distinct paths
• Claim Related Dispute
• Medical Necessity Dispute
• Medical Fee Dispute

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How do I know which path to take?
The reason(s) for denial of payment directs the
dispute resolution path
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Explanation of Benefits (EOB) will tell you
which path to take Carriers are required to use
American National Standards Institute (ANSI)
Claim Adjustment Reason Codes to pay, deny, or
reduce payment. http//www.wpc-edi.com
/
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What are Claim Related Denial Codes?

• Compensability
• (ANSI Code W11, 214)
• Extent of Injury
• (ANSI Code W12, 219)
• Liability
• (ANSI Code W2, 218)

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How can a health care provider know about a
potential denial for compensability or extent
prior to providing services?

• Some health care providers communicate with
  carrier (adjustor) prior to providing service
  about compensable conditions and any unresolved
  disputes
• Preauthorization approvals are required to
  indicate any unresolved issues of compensability
  or extent (Rule 134.600)

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What are some Medical Necessity Denial Codes?

• Unnecessary medical treatment based on peer
  review (ANSI 29, 216)
• These are non-covered services because this is
  not deemed a medical necessity by the payer
  (ANSI 50)

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What are some Medical Fee Denial Codes?

• Payment adjusted because the benefit for this
  service is included in the payment/allowance for
  another service/procedure that has already been
  adjudicated
• (ANSI - 97)
• No maximum allowable defined by fee guideline.
  Reimbursement made based on insurance carriers
  fair and reasonable reimbursement methodology
• (W10 ANSI - 217)

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What is a Medical Fee Dispute?
A disagreement about the denial or reduction of
reimbursement for compensable and medically
necessary healthcare already provided.
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When should a Medical Fee Dispute be submitted to
MFDR?

• After a request for reconsideration of DOS in
  question has been submitted and processed by
  carrier.
• When there are no claim related or medical
  necessity related denials/issues.
• When all billing and reimbursement timelines have
  been followed by DWC rules.

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What happens after I file with MFDR?

• Acknowledgement letter is sent to requestor and
  respondent
• Respondent receives the second complete copy of
  the dispute information and responds to MFDR and
  copy to requestor
• If any/or additional reimbursement is due, that
  amount plus interest will be ordered in the
  decision

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What happens if I dont agree with MFDRs
findings and decisions?
You can submit a request for hearing in writing
to the DWC Chief Clerk of Proceedings within 20
days of your receipt of our decision. The sought
amount will determine where your appeal will be
held. Contested Case Hearing (CCH) State Office
of Administrative Hearings (SOAH) Chief Clerk of
Proceedings/Appeals Clerk PO Box 17787-MS
35 Austin, TX 78744 Fax [phone]
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Medical Necessity (IRO) Dispute
Resources Phone number [phone] Fax
number [phone] TDI website (IRO
information) http//www.tdi.state.tx.us/hmo/iro_r
equests.html
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Medical Fee Dispute Resolution Resources Phone
number [phone] Fax number (512)
804-4811 Address DWC, MS 48 7551 Metro
Center Dr., Suite 100 Austin, TX
78744-1609 MFDR website http//www.tdi.state.tx.u
s/wc/mr/mfdr.html
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Changes
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• New Hospital Facility (outpatient and inpatient)
  fee guideline applicability date 3/1/08
• New Medical fee guideline applicability date
  3/1/08
• Ambulatory Surgical Center (ASC) fee guideline
  applicability date 1/1/08

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• Official Disability Guidelines (ODG)
  applicability date 5/1/07
• ODG can be updated often
• ODG Updates will be provided on the TDI-DWC
  website and emailed to those signed up for our
  listserv

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National Provider Identifier number (NPI)
Required DWC clean claims guide requires the use
of the NPI on your medical bills beginning May
23, 2008 just like Medicare Clean claims
guide http//www.tdi.state.tx.us/wc/ebill/index.h
tml
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• Electronic Billing!
• As of January 1st, 2008 every health care
  provider is required to be able to electronically
  bill workers comp medical bills (unless waived)
• Insurance carriers are required to electronically
  acknowledge receipt of medical bills
  electronically received
• If you are billing electronically for other
  payors, check with your clearinghouses for
  ebilling workers compensation bills

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Current Issues in Medical Fee Disputes
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• Network contracts non jurisdiction
• Non-network, informal, voluntary, and silent PPO
  contracts if denial due to contractual reasons,
  contract needs to be sent to MFDR with dispute
• ODG guidelines
• Zero pays for fair and reasonable codes
• Invalid codes if Medicare doesnt apply a value
  to a CPT code, it doesnt make it invalid but
  rather falls to fair and reasonable, carrier to
  assign a value
• Denial for medical necessity after
  preauthorization was issued
• 95 filing deadline
• Low Level Dispute Resolution (LLDR) process

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Dispute Resolution Myths
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Are health care providers charged an automatic
fee for filing a medical fee dispute?
No, however, the Division may assess a fee if
the provider billed an amount that is in conflict
of the division rules, including billing rules,
fee guidelines, or treatment guidelines. NOTE
The carriers may also be assessed a fee if they
denied or reduced payment in conflict with the
Division rules or other reasons as indicated in
Rule 133.305.
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Does Medical Fee Dispute Resolution issue
violations?
No, however, Medical Fee Dispute Resolution may
make a referral to System Monitoring and
Oversight for further review.
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Are health care providers charged an automatic
IRO fee for filing a medical necessity dispute?
No, not for preauthorization disputes reviewed
by an IRO. Yes, for retrospective medical
necessity disputes reviewed by an IRO, but if you
prevail, the carrier reimburses the fee back to
you.
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Can a health care provider bill the Injured
Employee if the carrier denies the bill as not
compensable?
No, not unless or until there is final
adjudication as non-compensable from the DWC
Field Office specifically for the
condition/diagnosis treated.
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What is final adjudication?
Either a Benefit Review Conference (BRC)
agreement between parties or Contested Case
Hearing (CCH) officer decision
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Can a health care provider pursue final
adjudication from the DWC Field Office?
Yes, the health care provider may file as a
sub-claimant to pursue final adjudication with
the local field office.
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What did I learn?

• How to file a dispute for medical fee, medical
  necessity and claim related denials
• Medical Dispute Resolution changes and myths

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