AP Reverses ALJ Who Added Fee Dispute Issue on his Own Motion
The Appeals Panel has reversed an ALJ’s Decision and Order and rendered a Decision to strike an issue added by the ALJ because the issue fell within the jurisdiction of the Division of Medical Review, rather than the Division of Hearings. The appeal is posted in Texas Division of Workers’ Compensation Appeals Panel Decision No. 182018, decided November 12, 2018.
The Division scheduled a CCH on the issue of whether the claimant had been properly provided with a notice of network requirements from the carrier’s Certified Healthcare Network. At the CCH, the ALJ, on his own motion and over objection by the carrier, added the following issue:
Is the carrier liable to pay for the MMI/IR evaluation by [Dr. R], a non-network physician, because the claimant was referred to him by the treating doctor for such evaluation?
The ALJ wrote in the statement of the case portion of the Decision that he added the issue “to reflect to [the] correct issue raised by the positions of the parties in this case. . . .” The ALJ held the record open for the parties to have the opportunity to provide briefs on the added issue. After receipt of the parties’ briefs, the ALJ closed the record and later issued a Decision and Order.
The ALJ first determined that the claimant had been properly provided with the notice of network requirements. He next concluded that the carrier was liable to pay for the MMI/IR evaluation by Dr. R, a non-network doctor, because the claimant was referred to him by the treating doctor for such evaluation. The carrier appealed the Decision to the Appeals Panel. The Appeals Panel struck the issue and reversed the decision of the ALJ, reasoning:
A dispute over payment for providing an MMI/IR examination is a medical fee dispute, which is adjudicated through the Division’s Medical Fee Dispute Resolution program (Chapter 413, Medical Review, of the Labor Code) or the network’s internal complaint resolution process (Chapter 1305, Workers’ Compensation Health Care Networks, of the Insurance Code). Accordingly, we reverse by striking the ALJ’s Conclusion of Law No. 3 and the decision that: “[t]he [c]arrier is liable to pay for the MMI/[IR] evaluation by [Dr. R], a non-network physician, because [the] [c]laimant was referred to him by the treating doctor for such evaluation.”
The claimant or the healthcare provider was, therefore, left to request medical dispute resolution with the Division’s Medical Review Department.
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