MEDICAL FEE DISPUTE RESOLUTION MFDR

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MEDICAL FEE DISPUTE RESOLUTION (MFDR)
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• Overview

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• What rules apply to Medical Dispute Resolution?
• 133.305 General Provisions
• 133.307 Resolution of Non-Network
  Medical Fee Disputes
• 133.308 Resolution by Independent Review
  Organization (both non- network and network)

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Are all disputes handled at the same place?

• There are three separate and distinct paths
• Claim Related Dispute
• Medical Necessity Dispute
• Medical Fee Dispute

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• How do I know which path to take?
• The reason (s) for denial of payment directs the
  dispute resolution path

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• Explanation of Benefits (EOB)
• will explain reduction or denial
• Carriers are required to use American National
  Standards Institute (ANSI) Claim Adjustment
  Reason Codes to pay, deny, or reduce payment.

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• Claim Related Denial Codes
• Compensability (ANSI Code W11, 214)
• Extent of Injury (ANSI Code W12, 219)
• Liability (ANSI Code W2, 218)

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• Medical Necessity Denial Codes
• Unnecessary medical treatment based on peer
  review (29, 216)
• These are non-covered services because this is
  not deemed a medical necessity by the payer
  (ANSI 50)

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• Medical Fee Denial Codes
• Payment adjusted because the benefit for this
  service is included in the payment/allowance for
  another service/procedure that has already been
  adjudicated (ANSI - 97)
• No maximum allowable defined by fee guideline.
  Reimbursement made based on insurance carriers
  fair and reasonable reimbursement
  methodology (ANSI - W10, 217)

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2
Claim Related Dispute
DWC-45 Request for a Benefit Review Conference
Local DWC Field Office
Medical Necessity Dispute
LHL009 Request for a Review by an IRO
Carrier/URA
DWC-60 Medical Fee Dispute Resolution Request
DWC - MFDR in Austin
Medical Fee Dispute
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What is a Medical Fee Dispute?
A disagreement about the denial or reduction of
reimbursement for compensable and medically
necessary healthcare already provided.
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When should a Medical Fee Dispute be submitted to
MFDR?

• After a request for reconsideration of DOS in
  
• question has been submitted and processed by
• carrier.
• When there are no claim related or medical
• necessity related denials/issues.
• When all billing and reimbursement timelines
  have
• been followed by DWC rules.

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• What happens after I file with MFDR?
• Acknowledgement letter is sent to requestor and
  respondent
• Respondent receives the second complete copy of
  the dispute information and responds to MFDR and
  copy to requestor
• If any/or additional reimbursement is due, that
  amount plus interest will be ordered in the
  decision

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What happens if I dont agree with MFDRs
findings and decision?
You can submit a request for hearing in writing
to the DWC Chief Clerk of Proceedings within 20
days of your receipt of our decision. The sought
amount will determine where your appeal will be
held. Contested Case Hearing (CCH) State Office
of Administrative Hearings (SOAH) Chief Clerk of
Proceedings/Appeals Clerk PO Box 17787-MS
35 Austin, TX 78744 Fax [phone]
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Medical Fee Dispute
2000.01 or greater
State Office of Administrative Hearings (SOAH)
Medical Fee Dispute
2000.00 or less
DWC Contested Case Hearing (CCH)
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• Medical Necessity (IRO) Dispute Resources
• Phone number [phone]
• Fax number [phone]
• TDI website (IRO information)
• http//www.tdi.state.tx.us/hmo/iro_requests.html

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• Medical Fee Dispute Resolution Resources
• Phone number [phone]
• Fax number [phone]
• Address DWC, MS 48
• 7551 Metro Center Dr., Suite 100
• Austin, TX 78744-1609
• MFDR website
• http//www.tdi.state.tx.us/wc/mr/mfdr.html

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• Changes
• Since last Educational Conference

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• New Hospital Facility (outpatient and inpatient)
  fee guideline applicability date 3/1/08
• New Medical fee guideline applicability date
  3/1/08
• Ambulatory Surgical Center (ASC) fee guideline
  applicability date 1/1/08
• Official Disability Guidelines (ODG)
  applicability date 5/1/07

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• Current Issues with
• Medical Fee Disputes

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• Network contracts non jurisdiction
• Non-network, informal, involuntary, and silent
  PPO contracts if denial due to contractual
  reasons, contract needs to be sent to MFDR with
  dispute
• ODG guidelines
• Zero pays for fair and reasonable codes
• Invalid codes if Medicare doesnt apply a value
  to a CPT code, it doesnt make it invalid but
  rather falls to fair and reasonable, carrier to
  assign a value
• Denial for medical necessity after
  preauthorization was issued
• 95 filing deadline
• Low Level Dispute Resolution (LLDR) process

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• Statistics

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• Questions????