The Division is once again referring medical fee disputes to the State Office of Administrative Hearings (SOAH) for contested case hearings. The Division put a hold on filing requests to docket with SOAH pending the final outcome of the litigation regarding the placement of the burden of proof at SOAH.  

On December 5, 2018, the Austin Court of Appeals held that the burden of proof remains on the health care provider in a medical fee dispute even when the carrier lost at the Division and is the appealing party. Facility Ins. Corp. v. Patients Med. Ctr, 574 S.W.3d 436, 443 (Tex. App.—Austin 2018, rev’d).    

The Texas Supreme Court reversed the Austin Court of Appeals on January 29, 2021. The Court held that “in a worker's compensation medical fee dispute resolution proceeding, the burden of proof in a contested case hearing before SOAH is on the party seeking review of the Division's initial MFDR decision. Accordingly, the court of appeals erred in holding that the burden always and necessarily remains on the provider.” Patients Med. Ctr. v. Facility Ins. Corp., 623 S.W.3d 336, 342 (Tex. 2021). Facility Insurance Corporation filed a motion for rehearing which was denied by the Texas Supreme Court on June 18, 2021. The Division resumed filing requests to docket cases with SOAH shortly thereafter.     

The Division took the pause in hearings as an opportunity to revise its process for referring cases to SOAH. The Division’s forms and process for referring cases to SOAH are much improved. The Division’s request to docket case letter to SOAH follows the Division’s plain language style by providing all of the necessary information in an easy-to-understand format.   

Although the process for referring cases to SOAH is significantly improved, there are likely to be far less medical fee disputes referred to SOAH.  According to the Division’s medical fee dispute resolution web page, there were a total of only 339 medical fee disputes pending at the Division as of August 2021, not including the air ambulance disputes.

The reasons for the significant drop in the number of medical fee disputes include the adoption of Medicare-based fee guidelines and workers’ compensation health care networks. Medicare provides more billing guidance than the Division’s former proprietary fee guidelines which leaves less room for disagreement between the parties.  Providing a maximum allowable reimbursement for more services also means fewer “fair and reasonable” disputes. And for claims covered by a workers’ compensation health care network, medical fee disputes are resolved through the network and not the Division.  

If you do go to SOAH, you don’t want to be the loser.  The loser at SOAH has to pay SOAH’s costs including its administrative law judge services at $100 per hour.  That rate was set in 2012.  No word yet on whether it will or has been increased.

       

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