8 CSR 50-2.030 - Resolution of Medical Fee Disputes
(1)
Procedures Pertaining to Applications for Payment of Additional Reimbursement
of Medical Fees (Reasonableness Disputes).
(A)
If an employer or insurer disputes the reasonableness of a medical fee or
charge, the employer or insurer shall notify the health care provider in
writing that the medical charge is being disputed and shall explain the basis
for the dispute. The employer or insurer may tender partial payment and the
health care provider may accept payment of the amount tendered without
prejudice to the filing of an application for payment of additional
reimbursement of medical fees. Upon receiving the written notice of the
dispute, the health care provider may contact the insurer or employer to
attempt to resolve the dispute.
(B)
In order to initiate a reasonableness dispute case, the health care provider
must first submit a Request for Case Status Information on a division-approved
form to the division prior to the filing of an application for payment of
additional reimbursement of medical fees. The health care provider shall file
with the division an original application for payment of additional
reimbursement of medical fees. The application shall contain all the following
information:
1. The name, address, and
telephone number of the health care provider;
2. Name, address, and telephone number of the
employer and insurer against whom the application is being filed;
3. Name, address, and Social Security number
of the employee for whom health care services were rendered, together with the
date of injury and date the services were provided, for all disputes;
4. The amount in dispute;
5. The date the first notice of the dispute
of the medical charge was received by the health care provider. Per section
287.140.4(2), RSMo, such notice shall be presumed to occur no later than five
(5) business days after transmission by certified United States mail;
and
6. Any additional information
the division deems necessary to resolve the dispute.
(C) The health care provider shall serve
through personal service or by certified mail, return receipt requested, a copy
of the application on the person or corporation against whom the application
has been filed. The health care provider shall file proof of service with the
division. The division shall send by first-class mail a copy of the application
to the employee, employer, insurer, or third-party administrator or their
attorneys of record as the case may be.
(D) The application shall be filed on a form
prescribed by the division and shall contain the required information. If the
application does not include all the information required by this rule or proof
of service is not filed with the division, the application will be rejected and
will be returned for the additional information.
(E) If no report of injury or claim for
compensation has been filed with the division for the injury for which the
health care was provided the application may be returned for lack of
jurisdiction.
(F) Upon receipt of
the application, the division will assign a medical fee dispute number and
confirm acceptance or rejection of the application to the health care
provider.
(G) After the filing of
an application for payment of additional reimbursement of medical fees, the
parties may attempt to resolve their dispute without the assistance of the
division.
(H) If the total amount
of the additional reimbursement sought is one thousand dollars ($1,000) or
less, and the parties are unable to resolve their dispute, either party may
file a written request for administrative ruling which request initiates the
administrative ruling procedure. All parties shall participate in the
administrative ruling procedure.
1. Within ten
(10) days of the receipt of the request for administrative ruling, the division
director shall assign the matter to the dispute management unit for an informal
summary review. The dispute management unit may require the health care
provider to provide information in support of its application for payment of
additional reimbursement of medical fees, such information to include, but is
by no means limited to, the following:
A.
Complete certified copies of itemized billing statements;
B. Complete certified copies of medical
records corresponding to the itemized billing statements;
C. Affidavit from the health care provider or
from health care provider's counsel stating the basis for health care
provider's belief that all the medical charges are fair and reasonable and are
not greater than the usual and customary fee as provided in section 287.140.3,
RSMo;
D. Copy of any contracts or
agreements between health care provider and employer or insurer.
2. The dispute management unit may
require the employer and/or insurer to provide information in defense of the
application for payment of additional reimbursement of medical fees, such
information to include, but is by no means limited to, an affidavit from the
employer or insurer, or counsel, stating the basis for employer/insurer's
belief that the medical charges are not fair or reasonable, or that the medical
charges are greater than the usual and customary fee as provided in section
287.140.3, RSMo.
3. No discovery
shall be allowed.
4. Within ten
(10) days of completion of its informal summary review, the dispute management
unit shall make a recommendation to the division director. Within ten (10) days
of the receipt of the dispute management unit's recommendation, the division
director shall issue an administrative ruling in the case awarding additional
reimbursement to the health care provider in an amount certain or denying
additional reimbursement in full.
5. The division shall, immediately upon
issuance of the administrative ruling, send a copy thereof by first-class mail
to counsel for all parties and to any party not represented by counsel. In the
event any party is aggrieved by the director's administrative ruling, that
party must file with the division's Jefferson City office a request for
evidentiary hearing within thirty (30) days of the date of the administrative
ruling, using the division-approved form. In the event no request for
evidentiary hearing is filed within thirty (30) days of the date of the
administrative ruling, the administrative ruling shall become the final and
conclusive determination in the case.
6. Upon timely filing of the request for
evidentiary hearing, the division shall assign the case to the local
adjudication office of proper venue for evidentiary hearing. The requesting
party may withdraw its request for evidentiary hearing, with prejudice, at any
time after the filing of the request and prior to the conclusion of the
evidentiary hearing. The withdrawal of the request for evidentiary hearing must
be in writing and must be signed by the party or counsel. The request for
evidentiary hearing may not be withdrawn without prejudice. Upon withdrawal of
the request for evidentiary hearing, the administrative ruling shall become the
final and conclusive determination in the case.
7. The evidentiary hearing shall be a simple
informal proceeding, and shall be held by an administrative law judge at a
place and time to be set by the division. The rules of evidence in civil cases
shall apply, except that the administrative law judge may consider the
information already obtained from the parties by the dispute management unit. A
record shall be made of the evidentiary hearing in the same manner as all other
evidentiary hearings, as set forth in section 287.460.1, RSMo. No discovery
shall be allowed unless specifically ordered in writing by the administrative
law judge assigned to the case, and only upon the showing of extraordinary
circumstances.
8. Within thirty
(30) days of the last day of the hearing, the administrative law judge shall
issue an award either awarding additional reimbursement to the health care
provider in an amount certain or denying additional reimbursement in full.
Either party may file an application for review with the Labor and Industrial
Relations Commission within twenty (20) days from the date of the award of the
administrative law judge. This review shall be subject to review and appeal in
the same manner as provided for other awards in Chapter 287, RSMo.
9. If the employer or insurer fails to comply
with the director's administrative ruling, the health care provider may file a
complaint with the division's fraud and noncompliance unit pursuant to section
287.128,
RSMo.
(I) If the total
amount of the additional reimbursement sought is more than one thousand dollars
($1,000), and the parties are unable to resolve their dispute, the health care
provider may file a written application for an evidentiary hearing of the
medical fee dispute. The health care provider shall forward a copy of the
application for an evidentiary hearing to all parties. The employer or insurer
shall file an answer to the application for an evidentiary hearing on a
division-approved form. The answer shall be filed within thirty (30) days from
the date of the application. The division may extend the thirty- (30-) day time
period for good cause. If the employer or insurer fails to file a timely answer
the facts contained in the application are deemed admitted as true, but
conclusions of law are not deemed admitted. An evidentiary hearing shall be
scheduled in front of an administrative law judge.
(J) Parties may engage in discovery to the
extent authorized by Chapter 287, RSMo.
(K) The evidentiary hearing shall be held at
a place and time to be set by the division. The division shall notify all
parties as to the time and place of the hearing. An administrative law judge
may continue the hearing for good cause. The hearing shall be simple and
informal and all parties shall be entitled to be heard and to introduce
evidence, however, the rules of evidence in civil proceedings shall apply. The
administrative law judge conducting the hearing shall issue an award deciding
the issues in dispute within thirty (30) days of the last day of the
hearing.
(L) Either party may file
an application for review with the Labor and Industrial Relations Commission
within twenty (20) days from the date of the award of the administrative law
judge. This review shall be subject to review and appeal in the same manner as
provided for other awards in Chapter 287, RSMo.
(M) The parties shall notify the division in
writing of the date and amount of any settlement of the application for payment
of additional reimbursement of medical fees.
(N) The division, without a hearing, may
reject an application for payment of additional reimbursements of medical fees
without prejudice for failure to follow the procedures of this rule.
(O) Any settlement of a reasonableness
dispute or award entered on the application for reimbursement of additional
medical fees shall prohibit the health care provider from pursuing any
additional fees for work-related medical treatment from the employee for the
health care services that were the subject of the application.
(P) Requesting and Issuing Awards on
Undisputed Facts.
1. An application for
payment of additional reimbursement of medical fees may be denied in full by an
administrative law judge without an evidentiary hearing by issuing an award on
undisputed facts in accordance with the following procedures. The employer or
insurer may file a request for an award on undisputed facts in regard to the
application for payment of additional reimbursement of medical fees on the
ground that same was not filed within the limitation period set forth in
section 287.140.4, RSMo, or on the ground that the charges have been paid in
full, or on any ground which would fully negate any liability for further
payment, and upon which ground the facts are not in dispute. The request for an
award on undisputed facts shall be filed on the approved division form. The
request for an award on undisputed facts shall state with particularity each
material fact as to which the employer or insurer claims there is no genuine
issue, with specific references to the contents of the application for payment
of additional reimbursement of medical fees, deposition testimony, affidavits,
and documents that demonstrate the lack of a genuine issue as to such facts.
Each request for an award on undisputed facts shall have attached thereto the
affidavits, portions of deposition transcripts, and other documents relied upon
in the request.
2. Within thirty
(30) days after a request for an award on undisputed facts is filed with the
division, the health care provider shall file its response thereto. The
response shall admit or deny each of the factual statements contained in the
request. A denial may not rest upon mere allegations or general denials.
Rather, the response shall support each denial with specific references to the
depositions, documents, or affidavits that demonstrate specific facts showing
that there is a genuine issue to be decided at an evidentiary hearing. Attached
to the response shall be a copy of the affidavits, deposition transcripts (or
portions thereof), and other documents upon which the response relies. The
response may also set forth, in detail, additional material facts that remain
in dispute.
3. Upon timely filing
of the response, the administrative law judge assigned to the case shall
proceed to ruling on the request for an award on undisputed facts. If no
response is filed within the thirty (30) days allotted, unless extended by
written order of an administrative law judge, the facts as set forth in the
request for an award on undisputed facts shall be deemed as true, and the
administrative law judge assigned to the case shall rule on the request for an
award on undisputed facts. If the request for an award on undisputed facts and
response show that there is no genuine issue as to any material fact and that
the application for payment of additional reimbursement of medical fees should
be denied in full, the administrative law judge shall issue an award on
undisputed facts denying the application for payment of additional
reimbursement of medical fees in full. Such award shall be a final reviewable
award in the case as to the application for payment of additional reimbursement
of medical fees.
4. The health care
provider may file an application for review with the Labor and Industrial
Relations Commission within twenty (20) days from the date of the award of the
administrative law judge. This review shall be subject to review and appeal in
the same manner as provided for other awards in Chapter 287, RSMo.
5. If the request for an award on undisputed
facts and response show that there is a genuine issue as to any material facts,
the administrative law judge shall issue an order denying the request for an
award on undisputed facts. An order denying the request for an award on
undisputed facts is not a final award as to any issue, and is not subject to
review or appeal.
(2) Procedures Pertaining to Applications for
Direct Payments (Direct Pay Disputes).
(A) If
an employer or insurer fails to make payment for authorized services provided
to an employee by a health care provider due to a work-related injury that is
covered under the Missouri Workers' Compensation Law, the health care provider
may file an application for direct payment with the division.
(B) The application for direct payment shall
contain the following information:
1. The
name, address, and telephone number of the health care provider and, if
different, the address where the service was rendered;
2. Name, address, and telephone number of the
employer and insurer against whom the application is being filed;
3. Name, address, and Social Security number
of the employee for whom health care services were rendered, together with the
date of injury, for all disputes;
4. A brief description of the disputed
services rendered; the date services were provided; the amount of money claimed
to be owed; and the name and title of the person from the insurer or employer
giving authorization;
5. Any
information the division deems necessary.
(C) The health care provider shall serve the
employer or insurer through personal service or by certified mail, return
receipt requested, a copy of the application on the person or corporation
against whom the application has been filed. The health care provider shall
file proof of service in accordance with section (4) of this rule with the
division. The division shall send by first-class mail a copy of the application
to the employee, employer, insurer or third-party administrator or their
attorneys of record as the case may be.
(D) The application shall be filed on a form
prescribed by the division and shall contain the required information. If the
application does not include all the information required by subsection (B) of
this section or proof of service is not filed with the division, the
application will be returned for the additional information.
(E) The division, without a hearing, may
reject an application for direct payment without prejudice if the application
does not pertain to a dispute relating to services that were authorized in
advance by the employer or insurer for a compensable injury or for failure to
follow the procedures of this rule.
(F) If there is no report of injury or claim
for compensation filed with the division for the work-related injury for which
the health care services were provided, the application will be returned for
lack of jurisdiction of the division.
(G) Upon filing of the application, the
division shall cause the application for direct payment to be made part of the
underlying workers' compensation case and shall notify the health care provider
of all proceedings relating to the underlying workers' compensation case. The
division shall notify all parties to the case that the application has been
made part of the underlying workers' compensation case. The health care
provider shall be granted standing to appear as a party in the underlying
workers' compensation case for the limited purpose of establishing that the
health care provider is entitled to payment for services rendered. The health
care provider shall have all rights accorded a party under Chapter 287, RSMo,
as to this limited issue.
(H) The
health care provider is barred from pursuing the employee for any work-related
costs incurred in pursuing the medical fee dispute and any reduction in payment
of a medical charge. This rule is not intended to prohibit the provider from
pursuing the responsible party for payment of fees for medical treatment that
is found by award or settlement not to be compensable.
(I) Requesting and Issuing Awards on
Undisputed Facts.
1. An application for direct
payment may be denied in full by an administrative law judge without an
evidentiary hearing by issuing an award on undisputed facts in accordance with
the following procedures. The employer or insurer may file a request for an
award on undisputed facts in regard to the application for direct payment on
the sole ground that the health care services for which direct payment is being
sought were not authorized by employer or insurer. The request for an award on
undisputed facts shall be filed on the approved division form. The request for
an award on undisputed facts shall state with particularity each material fact
as to which the employer or insurer claims there is no genuine issue, with
specific references to the contents of the application for direct payment,
deposition testimony, affidavits, and documents that demonstrate the lack of a
genuine issue as to such facts. Each request for an award on undisputed facts
shall have attached thereto the affidavits, portions of deposition transcripts,
and other documents relied upon in the request.
2. Within thirty (30) days after a request
for an award on undisputed facts is filed with the division, the health care
provider shall file its response thereto. The response shall admit or deny each
of the factual statements contained in the request. A denial may not rest upon
mere allegations or general denials. Rather, the response shall support each
denial with specific references to the depositions, documents, or affidavits
that demonstrate specific facts showing that there is a genuine issue to be
decided at an evidentiary hearing. Attached to the response shall be a copy of
the affidavits, deposition transcripts (or portions thereof), and other
documents upon which the response relies. The response may also set forth, in
detail, additional material facts that remain in dispute.
3. Upon timely filing of the response, the
administrative law judge assigned to the case shall proceed to ruling on the
request for an award on undisputed facts. If no response is filed within the
thirty (30) days allotted, unless extended by written order of an
administrative law judge, the facts as set forth in the request for an award on
undisputed facts shall be deemed as true, and the administrative law judge
assigned to the case shall rule on the request for an award on undisputed
facts. If the request for an award on undisputed facts and response show that
there is no genuine issue as to any material fact and that the application for
direct payment should be denied in full, the administrative law judge shall
enter an award on undisputed facts denying the application for direct payment
in full. Such award shall be a final reviewable award in the case as to the
application for direct payment.
4.
The health care provider may file an application for review with the Labor and
Industrial Relations Commission within twenty (20) days from the date of the
award of the administrative law judge. This review shall be subject to review
and appeal in the same manner as provided for other awards in Chapter 287,
RSMo.
5. If the request for an
award on undisputed facts and response show that there is a genuine issue as to
any material fact, the administrative law judge shall issue an order denying
the request for an award on undisputed facts. An order denying the request for
an award on undisputed facts is not a final award as to any issue, and is not
subject to review or appeal.
(3) In any dispute between a health care
provider and a managed care organization regarding medical care services or
payment of such services, the decision of the managed care organization is
subject to review by the division according to section 287.135.5,
RSMo.
(4) Except as otherwise
provided in this rule, each party filing any document with the division shall
mail or deliver to the opposing party a true and accurate copy of the document
filed with the division and shall certify or state on the document being filed
that such mailing or delivery has occurred.
(5) Requesting Records, Confidentiality and
Storage.
(A) The Report of Injury and
subsequent medical reports are considered closed records pursuant to section
287.380.3, RSMo. Section
610.021(14),
RSMo authorizes the division to close the records which are protected from
disclosure by law.
(B) If a person
submits records to the division and wishes to claim that the record is closed
or confidential, the division will maintain the record as closed, except that
information that is closed pursuant to section 287.380.3, RSMo will be provided
to a requesting person who is party to the workers' compensation case or an
attorney who has filed an entry of appearance representing a party to the
workers' compensation case or to a party in a reasonableness case. In order to
claim the record as closed or confidential, the person submitting the record
must state in bold or other clearly distinguishable type on the face of the
record or in the face of the cover letter accompanying the record, that the
record is closed or confidential and the reason the record is asserted to be
closed or confidential.
(C) The
requesting person may obtain records from the division by submitting a request
in writing to the division's Jefferson City office at PO Box 58, Jefferson
City, MO 65102. The requesting person must state their relationship to the case
as set forth in 8 CSR
50-2.020(4)(C). Records as legally
required will be provided in response to a subpoena duces tecum or Release of
Information form duly signed by the person giving the division authorization to
release the records.
(D) The
division will charge for copies of documents and certification of documents
according to section 287.660, RSMo, or Chapter 610,
RSMo, if applicable.
(E) The
division reserves the right to store the documentation submitted in a medical
fee dispute proceeding either electronically or in a paper
file.
(6) The
division-approved forms as referenced in these rules may be obtained from the
website address http://www.labor.mo.gov/div_pubs_forms.asp
or by contacting the division at (573) 522-2546, or by submitting a written
request to the division's Jefferson City office at PO Box 58, Jefferson City,
MO 65102.
Notes
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