Judge Halts Implementation of TWCC’s Alternate Medical Necessity Dispute Review Rule

The Texas Workers’ Compensation Commission (TWCC) reported that a Travis County District Judge has granted a temporary restraining order to prevent TWCC from implementing or enforcing new Commission Rule 133.309 (Alternate Medical Necessity Dispute Resolution by Case Review Doctor).

Commission Rule 133.309 was adopted at the Aug. 19 Commission public meeting and provides the exclusive process for retrospective review of medical necessity disputes where the sum of disputed billed charges is less than $650. The rule would have been effective for requests filed with the Commission on or after October 1, 2004.

Commission Rule 133.309 was adopted pursuant to the statutory provisions of Texas Labor Code §413.031 as amended by House Bill 3168 during the 2003 Texas Legislative Session. A new subsection was added to the Labor Code stating that the Commission may prescribe an alternate dispute resolution process to resolve disputes over medical services costing less than the cost of a review of the medical necessity of a health care service by an independent review organization.

The temporary restraining order was signed on Sept. 29, 2004 in the Travis County District Court, 345th Judicial District and remains in effect for 14 days. The order was requested in a lawsuit filed by the Insurance Council of Texas against the Commission.