Tex. Codes » Labor Code · TITLE 5. WORKERS' COMPENSATION · SUBTITLE A. TEXAS WORKERS' COMPENSATION ACT · CHAPTER 413. MEDICAL REVIEW
Texas Codes

Tex. Lab. Code § 413.016 (2026)

Payments In Violation Of Medical Policies And Fee Guidelines

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Sec. 413.016. PAYMENTS IN VIOLATION OF MEDICAL POLICIES AND FEE GUIDELINES. (a) The division shall order a refund of charges paid to a health care provider in excess of those allowed by the medical policies or fee guidelines. The division shall also refer the health care provider alleged to have violated this subtitle to the division of compliance and practices.

(b) If the division determines that an insurance carrier has paid medical charges that are inconsistent with the medical policies or fee guidelines adopted by the commissioner, the division shall investigate the potential violation. If the insurance carrier reduced a charge of a health care provider that was within the guidelines, the insurance carrier shall be directed to submit the difference to the provider unless the reduction is in accordance with an agreement between the health care provider and the insurance carrier.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.239, eff. September 1, 2005.

Notes of Decisions
Cited in 10 cases (1 in the last 5 years), 2005–2022 · leading case: Vista Med. Ctr. Hosp. v. Texas Mut. Ins. Co., 416 S.W.3d 11 (Tex. App.—Austin 2013).
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Vista Med. Ctr. Hosp. v. Texas Mut. Ins. Co., 416 S.W.3d 11 (Tex. App.—Austin 2013). · cites it 5× “” See Tex. Lab.Code § 413.016(a); Eckerd, 162 S.”
Daughters of Charity Health Servs. of Waco v. Linnstaedter, 226 S.W.3d 409 (Tex. 2007). “Tex. Lab.Code §§ 413.016, 413.042(a). 15 .”
Texas Mut. Ins. Co. v. Eckerd Corp., 162 S.W.3d 261 (Tex. App.—Austin 2005). “” See Tex. Lab.Code Ann. §§ 413.016(a), 413.019, 415.”
Vista Med. Ctr. Hosp. v. Texas Mut. Ins. Co., No. 03-11-00746-CV (Tex. App.—Austin June 6, 2013). · cites it 6× “023(b)(1), (4)). The Legislature’s provision of such procedures and remedies in the context of the act’s “comprehensive” regulatory scheme, we reasoned, evidenced intent that they serve as the sole means of initially determining and enforcing the statutory rights and duties at…”
Citizens Against the Landfill in Hempstead Michael McCall Wayne Knox & the City of Hempstead v. Texas Comm'n on Env't Quality & Pintail Landfill, L.L.C., No. 03-14-00718-CV (Tex. App.—Austin Feb. 25, 2015). · cites it 2× “016(a) "refunds" may arise from excessive reimbursement occurring due to a subse- quently reversed administrative order in a workers' compensation medical-fee dispute, in part because such coverage was contemplated by the regime under Tex. Lab. Code Ann §§ 413.”
Vista Med. Ctr. Hosp. Vista Healthcare, Inc. & Surgery Specialty Hosp., Inc.// State Off. of Risk Mgmt. v. State Off. of Risk Mgmt.// Vista Med. Ctr. Hosp. Vista Healthcare, Inc. & Surgery Specialty Hosp., Inc., No. 03-17-00352-CV (Tex. App.—Austin Aug. 22, 2018). “Tex. Lab. Code § 413.016(b). If no fee guideline or contract provision applies, the Commission requires carriers to provide a “fair and reasonable reimbursement amount” for the care provided.”
Facility Ins. Co. v. Vista Hosp. of Dallas, Vista Med. Ctr. Hosp. & Surgery Specialty Hospitals of Am., No. 03-18-00663-CV (Tex. App.—Austin Dec. 5, 2019). “(citing Tex. Lab. Code § 413.016(b)). But if no fee guideline (or negotiated contract) applies to a certain type of medical care, carriers must reimburse providers of that type of care at “a fair and reasonable reimbursement amount.”
Vista Med. Ctr. Hosp., Surgery Specialty Hosp. of Am., Se. Houston & Vista Hosp. of Dallas v. Texas Mut. Ins. Co., No. 03-21-00242-CV (Tex. App.—Austin Dec. 28, 2022). “; see also Tex. Lab. Code § 413.016(a) (requiring Division to order providers to refund payments that exceed guidelines).”
Texas Mut. Ins. Co.// Eckerd Corp. H.E. Butt Grocery Co. Third-Party Solutions, Inc. Wal-Mart Stores, Inc. Apollo Enter., Inc. & Walgreen Co. v. Eckerd Corp. H.E. Butt Grocery Co. Third-Party Solutions, Inc. Wal-Mart Stores, Inc. Apollo Enter., Inc. & Walgreen Co.//Cross-Appellee,Texas Mut. Ins. Co., No. 03-03-00704-CV (Tex. App.—Austin Jan. 21, 2005). “” See Tex. Lab. Code Ann. §§ 413.016 (a), 413.019, 415.”
Texas Mut. Ins. Co.// Eckerd Corp. H.E. Butt Grocery Co. Third-Party Solutions, Inc. Wal-Mart Stores, Inc. Apollo Enter., Inc. & Walgreen Co. v. Eckerd Corp. H.E. Butt Grocery Co. Third-Party Solutions, Inc. Wal-Mart Stores, Inc. Apollo Enter., Inc. & Walgreen Co.//Cross-Appellee,Texas Mut. Ins. Co., No. 03-03-00704-CV (Tex. App.—Austin Jan. 21, 2005). “" See Tex. Lab. Code Ann. §§ 413.016 (a), 413.019, 415.”
Tex. Lab. Code § 413.016(a): 5 cases
Vista Med. Ctr. Hosp. v. Texas Mut. Ins. Co., 416 S.W.3d 11 (Tex. App.—Austin 2013). “” See Tex. Lab.Code § 413.016(a); Eckerd, 162 S.”
Texas Mut. Ins. Co. v. Eckerd Corp., 162 S.W.3d 261 (Tex. App.—Austin 2005). “” See Tex. Lab.Code Ann. §§ 413.016(a), 413.019, 415.”
Vista Med. Ctr. Hosp. v. Texas Mut. Ins. Co., No. 03-11-00746-CV (Tex. App.—Austin June 6, 2013). “023(b)(1), (4)). The Legislature’s provision of such procedures and remedies in the context of the act’s “comprehensive” regulatory scheme, we reasoned, evidenced intent that they serve as the sole means of initially determining and enforcing the statutory rights and duties at…”
Citizens Against the Landfill in Hempstead Michael McCall Wayne Knox & the City of Hempstead v. Texas Comm'n on Env't Quality & Pintail Landfill, L.L.C., No. 03-14-00718-CV (Tex. App.—Austin Feb. 25, 2015). “016(a) "refunds" may arise from excessive reimbursement occurring due to a subse- quently reversed administrative order in a workers' compensation medical-fee dispute, in part because such coverage was contemplated by the regime under Tex. Lab. Code Ann §§ 413.”
Vista Med. Ctr. Hosp., Surgery Specialty Hosp. of Am., Se. Houston & Vista Hosp. of Dallas v. Texas Mut. Ins. Co., No. 03-21-00242-CV (Tex. App.—Austin Dec. 28, 2022). “; see also Tex. Lab. Code § 413.016(a) (requiring Division to order providers to refund payments that exceed guidelines).”
Tex. Lab. Code § 413.016(b): 3 cases
Vista Med. Ctr. Hosp. v. Texas Mut. Ins. Co., 416 S.W.3d 11 (Tex. App.—Austin 2013). “” See Tex. Lab.Code § 413.016(a); Eckerd, 162 S.”
Vista Med. Ctr. Hosp. Vista Healthcare, Inc. & Surgery Specialty Hosp., Inc.// State Off. of Risk Mgmt. v. State Off. of Risk Mgmt.// Vista Med. Ctr. Hosp. Vista Healthcare, Inc. & Surgery Specialty Hosp., Inc., No. 03-17-00352-CV (Tex. App.—Austin Aug. 22, 2018). “Tex. Lab. Code § 413.016(b). If no fee guideline or contract provision applies, the Commission requires carriers to provide a “fair and reasonable reimbursement amount” for the care provided.”
Facility Ins. Co. v. Vista Hosp. of Dallas, Vista Med. Ctr. Hosp. & Surgery Specialty Hospitals of Am., No. 03-18-00663-CV (Tex. App.—Austin Dec. 5, 2019). “(citing Tex. Lab. Code § 413.016(b)). But if no fee guideline (or negotiated contract) applies to a certain type of medical care, carriers must reimburse providers of that type of care at “a fair and reasonable reimbursement amount.”
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