State News : Texas

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DWC closes medical billing complaint loophole

On May 7, 2024, DWC adopted amendments to rule 180.2 concerning filing a complaint.  The amendments prevent health care providers from using the complaint process to circumvent the one-year filing deadline for medical fee disputes. The amended rule states:    
A health care provider cannot submit a complaint about a medical billing issue if the date of service for the medical billing issue was more than 12 months before the date of the complaint, unless the issue qualifies for an exception to the filing deadline under §133.307(c)(1)(B) of this title, concerning medical fee dispute resolution. If the issue qualifies for an exception to the medical fee dispute resolution filing deadline under §133.307(c)(1)(B), then a health care provider cannot submit a complaint about that issue if the medical fee dispute resolution filing deadline in §133.307(c)(1)(B) has passed. 
The rule also notes, “This subsection does not apply to a health care provider submitting a complaint under Insurance Code Chapter 1305.”  Section 1305.401 of the Workers’ Compensation Health Care Network Act requires each network to implement and maintain a complaint system to resolve complaints.  A health care provider may submit a complaint to the network over a fee dispute and if dissatisfied with the outcome, the provider may file a complaint with TDI’s complaint resolution process.

In-network fee disputes are not governed by Section 413.031 of the Workers’ Compensation Act and so there is not a one-year filing deadline for those disputes. DWC also does not have jurisdiction to resolve disputes over fees for medical services provided subject to a network contract.  Those are contract disputes that are governed by the terms of the contract between the network and health care provider and if the dispute is not resolved through the complaint process, it can be resolved through litigation or arbitration, if the contract mandates arbitration.