Opinion ID: 894529
Heading Depth: 1
Heading Rank: 4

Heading: Maximum Allowable Reimbursements

Text: Rule 134.201 establishes guidelines for reimbursements made for medical treatments or services rendered by health care providers. When a MAR is established for a particular medical treatment or service, the amount of reimbursement payable to a health care provider is the lesser of the provider's usual fees and charges or the MAR established in the Medical Fee Guideline. 21 Tex. Reg. at 2361. PAT argues that the Labor Code does not authorize TWCC to impose these caps on medical fees. TWCC responds that it must establish the MARs to carry out the Legislature's directives in the Workers' Compensation Act. TWCC relies on section 413.011 of Labor Code to support its contention that the Legislature granted it authority to set upper limits on medical payments through use of the MARs. A state administrative agency only has those powers that the Legislature expressly confers upon it or that are implied to carry out the express functions or duties given or imposed by statute. Pub. Util. Comm'n v. City Pub. Serv. Bd., 53 S.W.3d 310, 315-16 (Tex.2001); Pub. Util. Comm'n v. GTE-Southwest, Inc., 901 S.W.2d 401, 407 (Tex.1995); R.R. Comm'n v. Lone Star Gas Co., 844 S.W.2d 679, 685 (Tex.1992); see also Tex. Gov't Code § 2001.174(2)(A)-(B) (a reviewing court must reverse or remand a case for further proceedings if an agency's actions violate a statutory provision or exceeds the agency's statutory authority). In construing a statute, our objective is to determine and give effect to the Legislature's intent first by looking to the statute's plain and common meaning. Albertson's, 984 S.W.2d at 960. We liberally construe the provisions of the Workers' Compensation Act to carry out the Legislature's evident purpose of compensating injured workers and their dependents. Id. at 961; Lujan v. Houston Gen. Ins. Co., 756 S.W.2d 295, 297 (Tex. 1988). The Legislature vested TWCC with the power and authority to promulgate rules as necessary for the implementation and enforcement of the Workers' Compensation Act. Tex. Lab.Code § 402.061. Section 413.011 of the Labor Code is a mandate to TWCC to establish medical policies and guidelines relating to ... fees charged or paid for medical services for ... compensable injuries, including guidelines relating to payment of fees for specific medical treatments or services. Id. § 413.011(a)(1) (emphasis added). These guidelines must be fair and reasonable and designed ... to achieve effective medical cost control. Id. § 413.011(b). While the Legislature does not expressly instruct TWCC to set maximums on the amounts insurance carriers can reimburse health care providers for specific medical procedures, it does expressly require TWCC to achieve effective medical cost control and to establish guidelines for the payment of fees for specific medical services. See id. Establishing the MARs for medical treatments and services is an implied power that is reasonably necessary for TWCC to carry out the Legislature's intent. See City Pub. Serv. Bd., 53 S.W.3d at 315-16; GTE-Southwest, 901 S.W.2d at 407; Lone Star Gas, 844 S.W.2d at 685. TWCC's establishment of the MARs is therefore a valid exercise of its rulemaking power.