HOME » Texas Workers’ Compensation Carrier Pays $1.125 Million Case Study




This claim involved the provision of services that ended up exceeding $1.6 million in care, relating to a workers’ compensation case. Upon placement of the case, Convergent immediately initiated direct communication with the carrier and its bill review agent. The carrier asserted that it had audited the services, but without disclosing the specific results of any such audit. However, based on the audit, the carrier sought to obtain a dramatic payment reduction, offering to pay only $230,500 in final resolution on the claim. As the Texas Workers’ Compensation inpatient hospital fee schedule applied to the claim based on Convergent’s review, Convergent simply advised that the full amount due under the Texas fee schedule (143% of the comparable CMS allowance) would need to be paid in full.

In response, the carrier’s agent nearly doubled its offer and raised their proposed payment amount to $540,000, asserting that their Legal Department had previously filed medical fee disputes on cases involving similar issues, intimating that this route could be followed again. Convergent reiterated that the fee schedule amount would need to be paid, however, and the carrier then tendered an additional offer of $645,000.

After review of the claim, it was determined that additional dates of service for the patient would additionally need to be reduced to final billing, and added to supplement the patient’s stay. In light of this, Convergent advised that negotiation could not be considered until the final bill, including all interim segments had been completed, to allow for the final fee schedule calculation. In response to this, the carrier advised that the employer was in the process of changing workers’ compensation carriers, and that if a final agreement was not reached promptly, the payment process would then be delayed by months as a result of the transition between carriers.

Regardless of this, Convergent continued to work with the hospital to obtain a final billing which was obtained on an expedited timeline in light of the assertions made by the carrier. Upon receipt of the final bill and final DRG assigned to it, Convergent forwarded this information to the carrier and concurrently reviewed it to verify the applicable fee schedule allowance. Convergent verified that fee schedule allowance as $1.2 million.

After further discussions of this matter, the carrier’s agent communicated another increased offer, in the amount of $900,000. However, Convergent continued to maintain that the full schedule amount would be due. The carrier then raised its offer to one million dollars. When Convergent advised that this offer could not be accepted, the carrier advised that they would pull their offer off the table and set the claim up for audit. In response, Convergent requested the initiation of the process for an audit at the hospital to complete this process, as their offer was still not deemed acceptable.

The carrier then came back with yet another offer in the amount of $1.1 million. In response, Convergent again asserted that only the full fee schedule amount of $1.2 million could be accepted. After additional discussions with the carrier regarding this matter, Convergent presented a counter offer of $1.175 million conditional upon immediate issuance of the payment in question. In response to this offer, the carrier reasserted its intention to audit the bill, and to delay the release of any payment accordingly.

In the course of additional discussions regarding issues raised by the carrier regarding the extensive length of stay of the bill and other questions, and after additional communication with the hospital, Convergent finalized an agreement with the carrier for payment of $1.125 million in full and final satisfaction of the matter. This payment was duly and promptly issued, bringing the matter to a final conclusion based on payment of 94% of the fee schedule amount, with express preclusion of any present or future audit of the claim.