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Stop Loss Exception

October 23, 2008                                                      Bulletin 2008-No. 08


Division of Workers’ Compensation (Division) Staff met with insurance carrier representatives on October 22, 2008, to discuss a number of subjects.  This Bulletin is to report on the Division’s actions on the alleged stop-loss exception cases pending before the Division.


Mary Landrum, Director of Health Care Business Management, reported approximately 14,500 medical disputes remain pending at the Division, with approximately 11,000 involving medical fees.


The Division’s Commissioner of Workers’ Compensation, Rod Bordelon, has publicly stated that his goal is to reduce this back log of cases.  It has been reported that the Division is issuing Findings and Decisions in alleged stop-loss exception cases, awarding seventy-five percent of billed charges in many of those cases.  The Division is issuing these Findings and Decisions even though in its brief to the Austin Court of Appeals in Cause No. 03-07-00682-CV; Texas Mutual Insurance Company v. Vista Community Medical Center, L.L.P., the stop-loss exception case, the Division had stated that “fee guidelines were never intended to be entitlements or statements of a maximum payment amount.”  This statement is in direct contradiction to the Division’s position in the Patient Advocates case and what it is doing now in issuing its Findings and Decisions.


For more information on this subject, you can read the Amicus Curiae Brief of the Insurance Council of Texas at the following link:


Marisa Lopez Wagley, Enforcement Section, reported letters seeking information on hospital billing practices were expected to be sent to six hospitals this week.  Purportedly Surgery Specialty Hospitals of America f/k/a Vista Medical Center Hospital and Vista Hospital of Dallas are to be included among the recipients of the letters.



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