Resolution of Medical Fee Disputes

PURPOSE: This rule sets forth the Division of Workers’ Compensation administrative procedures available to employers, insurance carriers and health care providers to resolve disputes concerning charges for health care services, in accordance with section 287.140, RSMo. (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 thirdparty 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 divisionapproved 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 divisionapproved 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 workrelated 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) 5222546, or by submitting a written request to the division’s Jefferson City office at PO Box 58, Jefferson City, MO 65102. AUTHORITY: sections 287.140.4 and 287.650, RSMo Supp. 2013.* Emergency rule filed Feb. 3, 1993, effective Feb. 19, 1993, expired June 18, 1993. Emergency rule filed June 29, 1993, effective July 9, 1993, expired Nov. 5, 1993. Emergency rule filed Nov. 16, 1993, effective Nov. 26, 1993, expired March 25, 1994. Emergency rule filed June 28, 1994, effective July 8, 1994, expired Nov. 4, 1994. Emergency rule filed Oct. 20, 1994, effective Nov. 5, 1994, expired March 4, 1995. Emergency rule filed Aug. 18, 1995, effective Aug. 28, 1995, expired Feb. 23, 1996. Original rule filed Aug. 18, 1995, effective Feb. 24, 1996. Rescinded and readopted: Filed Jan. 21, 2000, effective Sept. 30, 2000. Emergency amendment filed Aug. 15, 2006, effective Sept. 1, 2006, expired Feb. 27, 2007. Amended: Filed Aug. 15, 2006, effective Feb. 28, 2007. Amended: Filed Nov. 12, 2013, effective May 30, 2014. *Original authority: 287.140, RSMo 1939, amended 1951, 1957, 1959, 1965, 1977, 1980, 1983, 1988, 1990, 1992, 1993, 1998, 2005 and 287.650, RSMo 1939, amended 1949, 1961, 1980, 1993, 1995, 1998.