TEXAS WORKERS COMPENSATION MEDICAL DISPUTES

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On June 19, 2012, The Division of Workers’ Compensation published a memorandum of how Medical Dispute Hearings will be handled starting on June 1, 2012. http://www.tdi.texas.gov/wc/idr/documents/drprocm0612.pdf The Division of Workers’ Compensation classifies medical disputes into two different classes, medical fee disputes and medical necessity disputes. Hearings for each are handled very differently. Medical Fee Disputes: All medical fee disputes are now handled through the same process regardless of the amount of the dispute. To start the hearing process, the party needs to complete a DWC-60 form to request a Benefit Review Conference at the field office of the Division of Workers’ Compensation. If the issue is not resolved at the Benefit Review Conference, the party may request a Contested Case Hearing at the State Office of Administrative Hearings. Medical Necessity Disputes: Disputes for medical treatment, including spinal surgery are done through this process, including networks, political subdivisions and pools. After the claim has gone through the Independent Review Organization (IRO), the appealing party needs to complete a DWC-49 requesting a Medical Contested Case Hearing at a field office of the Division of Workers’ Compensation. The Hearing Officer (Administrative Judge) shall consider evidence-based treatment guidelines adopted by the network, political subdivision or pool. The issues may be appealed into district court.

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