Texas Workers’ Compensation
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ORDER GRANTING PLEA IN JURISDICTION
The Texas Workers’ Compensation Commission filed a Plea in Jurisdiction seeking Summary Dispositions in the above cases. The cases were consolidated into one hearing with five other cases involving the same parties and similar facts, but the Plea in Jurisdiction involves only the two cases numbered above. The entire group of seven cases was referred to mediation but no settlement was reached and the hearing on the plea and the merits of the cases was held on December 21, 2001. The record closed on January 25, 2002. The Fund argued that the Commission has jurisdiction to order the refund of the amounts it has already paid to Dr. Harph. The Commission and Dr. Harph disagreed.
The facts concerning the medical payment and request for the refund are not in dispute; therefore, they are addressed in the Findings of Fact without further discussion here.
The Plea in Jurisdiction is granted because the Commission and, therefore, SOAH does not have jurisdiction because the health care provider was not denied payment or paid a reduced amount for those services, as is required for jurisdiction under TEX. LABOR CODE §413.031(a)(1) and because the Fund did not send a Notice of Medical Payment Dispute regarding those services, as is required by TEX. LABOR CODE §408.027(d) and 28 TAC §133.304.
FINDINGS OF FACT
- In both Docket Nos. 453-99-1533.M4 and 453-00-1809.M4 Dr. Harph billed CPT Codes 22558-22, 22585-22, and (twice in each case) 22845-65.
- The Texas Workers’ Compensation Insurance Fund (the Fund) paid various amounts for these services.
- The Fund requested a refund of the above payments from Dr. Harph.
- The Fund did not provide Dr. Harph with a report explaining the reasons for the reduction or denial of payment ( Notice of Payment Dispute).
- Dr. Harph requested a hearing on this matter on July 19, 1999.
- The hearing was convened December 21, 2001, at the offices of the State Office of Administrative Hearings in Austin, Texas. Administrative Law Judge John H. Beeler presided. Carrier appeared through its attorney, Jeff Boggess. Dr. Harph appeared by telephone and represented himself. The Commission was represented by its assistant general counsel, Timothy Riley. The hearing concluded that same day, but the record was left open to allow the parties to file written arguments. The record closed on January 25, 2002.
CONCLUSIONS OF LAW
1.The issue of a refund is not properly before the Commission because the Fund did not deny payment or pay a reduced amount for the services for which it sought a refund. TEX. LABOR CODE §413.031(a).
2.The refund issue is not properly before the Commission and the State Office of Administrative hearings because no Notice of Payment Dispute was provided to Dr. Harph. TEX. LABOR CODE §408.027(d).
3.Dr. Harph should not be ordered to refund amounts previously paid to him by the Fund for services rendered in Docket Nos 453-99-1533.M4 and 453-00-1809.M4.
IT IS, THEREFORE, ORDERED that the request of Petitioner, Texas Workers’ Compensation Insurance Fund, for a refund of monies paid to Dr. Harph is denied.
Signed this 25th day of March, 2020.
JOHN H. BEELER
Administrative Law Judge
State Office of Administrative Hearings