Medical Fee Dispute Resolution The Basics

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Medical Fee Dispute ResolutionThe Basics

• Martha Luevano
• Manager, MFDR

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Welcome
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Agenda

• MFDR Big Picture
• Is MFDR the Correct Dispute Track?
• Filing a Medical Fee Dispute
• Possible Outcomes of a Medical Fee Dispute
• Common Issues in MFDR Today
• Customer Service
• Question Answer

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MFDR Big Picture

• What is a Medical Fee Dispute?
• A disagreement over the amount of payment due
  for health care determined to be medically
  necessary and appropriate for treatment of a
  compensable injury, given the relevant statutory
  provisions and Division rules.
• Who may request Medical Fee Dispute Resolution?
• Providers, injured employees, Pharmacy
  Processing Agents and other entities as specified
  by rule.
• What Rules apply in Medical Fee Dispute
  Resolution?
• Texas Labor Code Rule 133.305 133.307 set
  out eligibility and requirements and filing
  requirements.

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MFDR Big Picture

• What are the common reasons for filing a Fee
  Dispute?
• If a requestor believes that a medical bill was
  reduced or denied contrary to the rules of the
  Division, they may be able to file a dispute.
• What should I consider before filing for Fee
  Dispute?
• Filing for Medical Fee Dispute is a business
  decision. MFDR reviews all documentation provided
  by both parties in a dispute and determines the
  outcome based on the applicable rules and statues.

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MFDR Big Picture

• Does MFDR adjudicate disputes involving
  contracts?
• MFDR may adjudicate disputes involving informal
  or voluntary contracts. However, if the medical
  service involves a Certified Health Care Network
  under chapter 1305 of the Insurance code, MFDR
  will refer the dispute to the appropriate program
  area.

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Understanding Dispute Tracks
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Is MFDR the correct dispute track?

• Step 1 Medical services are rendered, billed
  and subsequently reduced or denied by the
  insurance carrier.
• Step 2 Requestor disagrees with the reasons for
  reduction or denial of payment.
• Step 3 The claim adjustment codes are the key
  to determining which dispute track is appropriate

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Reference Table for Dispute Resolution
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Filing for Medical Fee Dispute
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Form DWC-060

• Download DWC Form-060, Medical Fee Dispute
  Resolution Request from TDI-DWC website.
• Complete DWC Form-060 (Parts I, II, and V).
• List all dates of service for the medical bills
  in dispute.  
• Send or deliver two copies of dispute to the
  TDI-MFDR Section.
• Your request must be filed with TDI-DWC MFDR
  Section no later than one year after the date(s)
  of service in dispute (For exceptions see 28
  Texas Labor Code 408.0271)
• The TDI-DWC shall deem a request to be filed on
  the date the TDI-DWC MFDR Section receives the
  request.

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Documentation to Include with the DWC-060

• A copy of all medical bill(s) as originally
  submitted to the carrier.
• A copy of all medical bill(s) submitted to the
  insurance carrier for reconsideration in
  accordance with TAC 133.250.
• A copy of each explanation of benefits (EOB). 
• If no EOB, convincing documentation providing
  evidence of insurance carrier receipt of the
  request for an EOB.
• DWC Form-060 table listing the specific disputed
  health care and charges.
• A copy of all applicable medical records specific
  to the date(s) of service in dispute.
• A position statement of the disputed issue
• Any other documentation that the requestor wishes
  to include in order to support or supplement
  their position.

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Requestor completes PART I II

DWC Claim
Carrier Claim
Send the completed form to this address
www.tdi.state.tx.us
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Respondent completes PART III
DWC completes PART IV
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Requestor Respondent complete PART V
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Processing of Disputes

• Once the complete DWC-060 package is received, an
  acknowledgement letter is sent to requestor and
  respondent.
• The Respondent receives the second complete copy
  of the dispute and is given the opportunity to
  respond.
• MFDR reviews the dispute in accordance with DWC
  statues and rules.
• MFDR may provide education, as needed, contact
  parties for additional information, and may raise
  issues.

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Possible Outcomes

• Requestor Withdrawal A requestor may choose to
  withdraw from Medical Fee Dispute if they no
  longer wish to pursue the dispute. Common reasons
  for withdrawn include
• Requestor determines the dispute was filed in
  error or as a misunderstanding of Division
  statues or rules.
• Parties to the dispute informally resolve the
  dispute resulting in an outcome satisfactory to
  the requestor.
• MFDR Decision and Order MFDR may issue a
  findings and decision. Parties to the dispute
  receive a written Decision and Order.

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Appeal of MFDR Decision Order

• Appeals Parties to a dispute have the right to
  appeal an MFDR Decision and Order if they
  disagree with the outcome. Detailed instructions
  on how to appeal a decision are included on every
  Decision issued by MFDR.

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Common Issues with DWC-060 Packages

• The dispute as filed does not meet the
  requirements of Rule 133.307. In all these
  cases, requestors are contacted and education is
  provided. Common issues include but are not
  limited to
• Dates of service exceed the one-year filing
  deadline.
• No proof or reconsideration in accordance with
  Rule 133.250
• Denial codes indicate that Medical Fee Dispute is
  not the appropriate dispute track.
• Fee Disputes involving a Certified Health Care
  Network (HCN) under chapter 1305 of the Insurance
  Code are not handled through MFDR. These
  disagreements are handled through the appropriate
  Network complaint process. HWCN is the program
  area that oversees the HCN. You may find more
  information at http//www.tdi.state.tx.us/wc/wcnet
  /index.html

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MFDRs Mission
If we HAVE.. P articipation R esponsiveness I
crease Efficiency D emonstrate Explain E
ducation Communication
.there will be
No Surprises
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Contact Information and Resources for MFDR

• MFDR telephone number  [phone]
• MFDR fax number  [phone]
• DWC address  MS 48, 7551 Metro Center Drive,
  Austin, TX 78744
• MFDR website  http//www.tdi.state.tx.us/wc/mfdr/
  
• MFDR E-mail Address MDRInquiry.ATLAS_at_TDI.state.tx
  .us
• DWC-060 Checklist http//www.tdi.state.tx.us/wc/m
  fdr/mdrchecklisthcp.html

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Questions?
This presentation was produced by the Medical Fee
Dispute Resolution Section of the Division of
Workers Compensation, Texas Department of
Insurance, 7551 Metro Center Drive, Suite 100,
Austin, Texas, 78744 [phone]. This
information is for educational purposes and is
not a substitute for the statute and rules.