Medical Fee Disputes
A medical fee dispute ("MFD") is a proceeding filed by a health care provider when there is a dispute about the payment of bill(s) for medical treatment. There are two types of medical fee disputes: "Reasonableness", when the bill has been discounted and partially paid, and "Direct Pay", when treatment has been authorized but no payment has been made on the bill. Each MFD type has a seperate procedure.
Reasonableness Disputes or Request for Additional Reimbursement
In a reasonableness medical fee dispute, the employer/insurer has authorized treatment for a recognized workers' compensation injury and has paid a portion of the bill. The issue to be decided in this type of MFD is the fairness and reasonableness of the charges for medical treatment. The reasonableness MFD is not a part of the underlying workers’ compensation case. When this type of MFD is filed, it proceeds separately from the underlying case. The employee is not a party to a reasonableness MFD and his or her right to workers' compensation benefits cannot be jeopardized by the dispute.
If the health care provider (“HCP”) and the employer/insurer are unable to come to a resolution of the dispute on their own, the health care provider must file an application with the Division to proceed. The procedure for application for payment is as follows, in cases where the amount in dispute is in excess of $1,000:
- The health care provider initially files an Application For Payment of Additional Reimbursements of Medical Fees with the Division.
- The health care provider serves a copy of the application on the employer/insurer through personal service or by certified mail, return receipt requested.
- A MFD Number is assigned.
- If the parties are unable to resolve the dispute, the healthcare provider may file a written application for an evidentiary hearing with the Division.
- The health care provider forwards a copy of the application for evidentiary hearing to all parties to the medical fee dispute.
- The local adjudication office of proper venue sets an evidentiary hearing and notifies all parties of the date and time.
- The employer/insurer files an Answer to Application for Payment of Additional Reimbursement of Medical Fees within 30 days from the date of the application.
- An administrative law judge conducts the hearing and an award is issued.
The final award in the reasonableness MFD has no effect upon the employee’s right to benefits from the employer/insurer.
In cases where the amount in dispute is $1,000 or less, the parties must participate in an administrative ruling procedure, described in the following paragraphs.
If the total amount of the additional reimbursement sought is $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.
- Within 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:
- Complete certified copies of itemized billing statements;
- Complete certified copies of medical records corresponding to the itemized billing statements;
- 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
- Copy of any contracts or agreements between health care provider and employer or insurer.
- 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 reasonable, or that the medical charges are greater than the usual and customary fee as provided in Section 287.140.3, RSMo.
- No discovery shall be allowed.
- Within 10 days of completion of its informal summary review, the Dispute Management Unit shall make a recommendation to the Division Director. Within 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.
- 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 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 30 days of the date of the administrative ruling, the administrative ruling shall become the final and conclusive determination in the case.
- Upon timely filing of the request to 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.
- 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, as set 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.
Within 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 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.
Related: Dispute Management
Direct Payment Disputes
In a direct pay medical fee dispute, the employer/insurer refuses to pay for medical treatments that the health care provider contends were authorized under workers' compensation. In these instances the employer/insurer may be contesting whether the injury or occupational diseases is compensable under the Missouri Workers' Compensation Law. If an employer/insurer and the health care provider are unable to come to a resolution of the dispute without the involvement of the Division, the health care provider may file an application as follows:
- The health care provider initially files a Notice of Services Provided and Request for Direct Payment with the Division;
- The health care provider then serves a copy of the application on the employee and the employer/insurer through personal service or by certified mail, return receipt requested;
- A Medical Fee Dispute Number is assigned;
- The health care provider is made a party to the underlying workers’ compensation case. It gives the health care provider representative the right to appear in the workers’ compensation case to establish that services were authorized by the employer/insurer and therefore the health care provider is entitled to payment;
- When the case is set on a docket all parties to the case, including health care provider, are notified;
- It is the health care provider's responsibility to be represented at all dockets;
- The health care provider may participate in and present evidence at any evidentiary hearing;
- Venue is determined by Section 287.640, RSMo.
Note: The administrative law judge may (but is not required to) order that the health care provider be paid directly from the proceeds of a settlement or award in the case.
When the employer/insurer believes that the medical services, which are the subject of the request for direct payment, were not authorized by the employer/insurer, the employer/insurer may file a request for award on undisputed facts, pursuant to the procedures outlined in 8 CSR 50-2.030 (2) (I).