Missouri Code of State Regulations › Title 8 - DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS › Division 50 - Division of Workers' Compensation › Chapter 2 - Procedure › Section 8 CSR 50-2.030 - Resolution of Medical Fee Disputes

Current through Register Vol. 49, No. 14, July 15, 2024
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.
				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.
				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 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; 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 reason able, 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, asset 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.