TX Proposed MDR Rules

Pursuant to HB 724, HB 1003, and HB 2004, medical necessity or medical fee disputes must now go through a proper hearing before parties can seek judicial review.  For all medical fee disputes above $2,000.00 and all medical necessity disputes above $3,000.00 the parties will request a Contested Case Hearing (CCH) through the State Office of Administrative Hearings (SOAH).  All other disputes (preauthorization or concurrent review denials, medical fee disputes up to and including $2,000.00, and medical necessity disputes up to and including $3,000.00), a CCH will be held at a Division of Workers’ Compensation field office. 

The new rules specify that all doctors employed by the Independent Review Organization must be licensed in Texas.  Moreover, the new rules require IRO doctors have the requisite education, training, and experience to provide all health care reasonably required by the nature of the injury to treat the condition until further material recovery or lasting improvement to the injury can no longer reasonably be anticipated.  The Division chose not to use a more stringent certification or of “like specialty” language.  Further, the IRO doctor’s qualifications are not just subject to the treatment being proposed, but for all the treatment that may become necessary to treat the injury until the claimant reaches maximum medical improvement.  A party may file a request for a letter of clarification to the IRO no later than ten days prior to the hearing.  The IRO is to respond within five days.  It is unclear if the Division will grant a continuance or motion to leave the record open to receive the IRO response to the letter of clarification.

The most controversial aspect of the proposed rules create a dichotomy between a hearing before SOAH and a hearing before the Division.  SOAH will not adopt the same rules as the Division.  Therefore, the Division has two choices: (1) Adopt rules similar to SOAH; or (2) Adopt it’s own procedures.  Most stakeholders prefer the former.

The difference between dispute resolution hearings handled by SOAH and those handled by the Division is determined by an arbitrary number ($2,000.00 for medical fee disputes and $3,000.00 for medical necessity disputes).  All prospective medical disputes will be determined by the Division.  Stakeholders would benefit by consistent rules and procedures for hearings whether they are before SOAH or the Division. 

Unfortunately, the Division chooses to implement their own rules that are very different from SOAH with no justification for the difference.

The Division rules place more limits on evidence that can be considered.  It is unclear why the Division believes less evidence would lead to better decisions.  A best practice approach would align both procedural and evidentiary rules with those already established by SOAH which has more expertise in developing dispute resolution rules.