Changes to Texas HB 2605

by Holly Hayes

The following changes to HB 2605 impacting the resolution of medical fee disputes within the Texas Department of Insurance, Division of Workers’ Compensation were adopted on May 11, 2012, and become effective May 31, 2012.

HB 2605 made several legislative amendments that impact the resolution of medical fee dispute cases adjudicated by the Division. This bill enacted Labor Code §413.0312, which alters the appeals process applicable to medical fee disputes after the Division’s review under Labor Code §413.031. Newly added Labor Code §413.0312 provides one appeal process for medical fee disputes regardless of the amount of reimbursement sought. Prior to the enactment of HB 2605, appeals of medical fee disputes were handled by a Division contested case hearing (CCH) if the amount of reimbursement sought by the requestor in an individual fee dispute was $2,000 or less or a contested case hearing conducted by the State Office of Administrative Hearings (SOAH) if the amount of reimbursement sought exceeded $2,000. Parties who had exhausted all administrative remedies and who were aggrieved by the final decision of SOAH could seek judicial review of the decision in the manner provided for judicial review of a contested case under Chapter 2001, Subchapter G Government Code.

Pursuant to Labor Code §413.0312, the appealing party is now required to mediate the medical fee dispute at a benefit review conference (BRC) under Labor Code Chapter 410, Subchapter B. If the dispute remains unresolved after a BRC, the parties may elect to engage in binding arbitration as provided by Labor Code §413.0312(d) and under Chapter 410, Subchapter C. However, if arbitration is not elected, the party is entitled to a contested case hearing at SOAH to resolve the dispute in the manner provided for a contested case under Chapter 2001, Government Code. A party who has exhausted all administrative remedies and who is aggrieved by a final decision of SOAH may seek judicial review of the decision in the manner provided for judicial review of a contested case under Chapter 2001, Subchapter G Government Code and Labor Code §413.031(k-1).