Sunday, May 30, 2004

New Texas Supreme Court case on workers' comp.

Texas Workers' Compensation Commission v. Patient Advocates of Texas, No. 02-0804, decided May 28:
In 1989, the Legislature enacted a new Workers’ Compensation Act in response to rising medical costs and increasing insurance premiums. The Legislature created the Texas Workers’ Compensation Commission and gave the agency broad powers to adopt rules necessary for the implementation and enforcement of the Workers’ Compensation Act. TEX. LAB. CODE § 402.061. One of TWCC’s new functions was to establish fee guidelines for reimbursements to health care providers who treat injured workers. Id. § 413.011. To this end, the agency promulgated the Texas Workers’ Compensation Commission Medical Fee Guideline 1996, adopted by reference in Rule 134.201 of the Texas Administrative Code. See 28 TEX. ADMIN. CODE § 134.201 (indicating that copies of the Guideline may be obtained from TWCC’s publication department). The Guideline contains the maximum allowable reimbursements (MARs) for thousands of medical procedures. The MARs establish upper limits on the amount of reimbursements payable to health care providers for the listed treatments or services. TWCC also promulgated a set of rules, now commonly referred to as the “Dispute and Audit Rules,” which establish a process for insurance carriers to review and audit bills submitted by health care providers. Id. §§ 133.301-.305.2 The rules also set up dispute resolution procedures to resolve disagreements over the necessity of medical procedures and the amount of reimbursements. Id. § 133.305. Requests for medical dispute resolution must be filed not later than one year from the date of the medical service. Id. § 133.305(d).

TWCC’s adoption of the Guideline and the Dispute and Audit Rules are at the base of this dispute. Patient Advocates of Texas and Allen J. Meril, M.D. (collectively PAT) initiated this lawsuit claiming that TWCC did not follow the rulemaking procedures required by statute when promulgating the Guideline. Additionally, PAT asserts that TWCC exceeded its rulemaking authority by setting a ceiling on many medical fee reimbursements and limiting the time for a party to seek medical dispute resolution to one year from the date the medical service was provided. PAT also challenges the validity of the Dispute and Audit Rules alleging that TWCC illegally delegated its audit and fee-setting authority to private insurance carriers. Lastly, PAT raises constitutional challenges to the rules on the grounds that the MARs and the one-year time limitation constitute a taking of their property without due process and just compensation. In response, TWCC argues that its enactment of the Guideline meets statutory procedural requirements and the limits placed on medical payments are consistent with the agency’s authority to establish medical policies and guidelines pursuant to section 413.011 of the Labor Code. TWCC claims that it retains its power to audit workers’ compensation participants and establish medical fees, and that the Dispute and Audit Rules are simply a means to facilitate insurance carriers’ review of the medical claims submitted by health care providers.
The Supreme Court concludes "that TWCC complied with the statutory requisites for promulgating the fee guidelines and acted within its designated powers in limiting specified medical fee reimbursements and the time to seek medical dispute resolution. We affirm the court of appeals’ judgment on these issues. Because we conclude that TWCC did not delegate its power to private entities, we reverse the portion of the court of appeals’ judgment that is contrary to this conclusion. We also overrule the constitutional challenge to TWCC’s fee reimbursement guidelines and time limitations for commencing medical dispute resolution."

8 comments:

Anonymous said...

Hi,
Are you sick of feeling unwell? My site is full of great articles all about alternative health. Why don't you drop by and have a quick peek.
Peace,
Bradford
http://bradfordmoore.com/health/

Anonymous said...

Wow, this information is a cut above. Keep up the great work. The posts are very informative.
Thanks,
alternative health http://www.alternativehealthreporter.com

Anonymous said...

Cool blog thanks for posting this information.

Anonymous said...

hey what a nice site . your blog is great .regards quick payday loan

Anonymous said...

I decided to post on this blog as a way to keep my friends informed of whats going on with home insurance . It is more like a journal of my life that I'm happy to share.

Anonymous said...

if people come to a blogspot to read secrets, then, it'd be just as fair for
the author to use the details of those who came to the blogspot page for his or her own use. Individual health insurance

Anonymous said...

Hello there ##NAME##, I'm out surfing for a good
blog on same day payday loan and found your great site. Although
##TITLE## wasn't exactly what I'm looking for it
certainly got my attention and interest. I see now why
I found your excellent blog-site when I was searching
for same day payday loan related web sites and I'm glad I
found your site even though its not an exact match.
Excellent Post, thank you for the read. Please check
out my site - same day payday loan.

Anonymous said...

Hi ##NAME##, today I'm surfing for a good blog
experience on ##LINK## and I found your great site.
Well ##TITLE## wasn't exactly what I was looking for
it did receive my attention and interest. I see now
why I found your resourceful web-site when I was
searching for ##KEYWORD## related information and I am
glad I found your site even though its not an exact
find.