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Introduction

The primary responsibility of the local adjudication offices of the Division of Workers' Compensation is to achieve resolution of cases involving work-related injuries due to accidents or occupational diseases. An important component of this responsibility is to provide impartial administrative adjudication services in a timely and cost effective manner. The administrative law judges also have original jurisdiction in cases involving victims of crime and tort victims.

Medical Fee Disputes

A medical fee dispute is a proceeding filed by a health care provider when there is a dispute about the payment of bill(s) for medical treatment. There are two types of medical fee disputes (MFD): “Reasonableness”, when the bill has been discounted and partially paid, and “Direct Pay”, when treatment has been authorized but no payment has been made on the bill. Each MFD type has a separate procedure.

Medical Fee Disputes – Reasonableness

In a reasonableness medical fee dispute (MFD), the employer has authorized treatment for a recognized workers' compensation injury and has paid a portion of the bill. The issue to be decided in this type of MFD is the fairness and reasonableness of the charges for medical treatment. The reasonableness MFD is not a part of the underlying workers’ compensation case. When this type of MFD is filed, it proceeds separately from the underlying case. The employee is not a party to a reasonableness MFD and his or her right to workers' compensation benefits cannot be jeopardized by the dispute.

If the health care provider (HCP) and the employer/insurer are unable to come to a resolution of the dispute on their own, the health care provider must file an application with the Division to proceed. The procedure for application for payment is as follows:

1. The health care provider files a Form WC-MD-02 Application For Payment of Additional Reimbursements of Medical Fees with the Division.
2. The health care provider serves a copy of the application on the employer/insurer through personal service or by certified mail, return receipt requested.
3. A Medical Fee Dispute Number is assigned.
4. The health care provider and employer/insurer must again try to resolve the dispute without the assistance of the Division.
5. If there is no resolution of the dispute in sixty (60) days after the filing of the application form, the health care provider may file a written application for a Medical Fee Dispute Proceeding (WC-MD-03). Venue is determined pursuant to Section 287.640, RSMo.
6. The health care provider forwards a copy of the application for evidentiary hearing to all parties to the medical fee dispute.
7. The local adjudication office of proper venue sets an evidentiary hearing and notifies all parties of the date and time (Form WC-160).
8. The employer/insurer must file an answer to the application within thirty (30) days of the application for evidentiary hearing.
9. An administrative law judge conducts the hearing and an award is issued.

The final award in the reasonableness MFD has no effect upon the employee’s right to benefits from the employer/insurer.

Medical Fee Disputes – Direct Pay

In a direct pay medical fee dispute, the employer/insurer refuses to pay for medical treatments that the health care provider contends were authorized under workers' compensation. In these instances the employer/insurer may be contesting whether the injury or occupational disease is compensable under the Missouri Workers' Compensation Law. If an employer/insurer and the health care provider are unable to come to a resolution of the dispute without the involvement of the Division, and more than ninety (90) days have elapsed since the date of the first billing, the health care provider may file an application as follows:

1. The health care provider files a Form WC-MD-01 Notice of Services Provided and Request for Direct Payment with the Division;
2. The health care provider then serves a copy of the application on the employee and the employer/insurer through personal service or by certified mail, return receipt requested;
3. A Medical Fee Dispute Number is assigned;
4. The health care provider is made a party to the underlying workers’ compensation case. It gives the health care provider representative the right to appear in the workers’ compensation case to establish that services were authorized by the employer/insurer and therefore the health care provider is entitled to payment;
5. When the case is set on a docket all parties to the case, including health care provider, are notified;
6. It is the health care provider's responsibility to be represented at all dockets;
7. The health care provider may participate in and present evidence at any evidentiary hearing;
8. Venue is determined by Section 287.640, RSMo.

Note: The administrative law judge may (but is not required to) order that the health care provider be paid directly from the proceeds of a settlement or award in the case.

Voluntary Settlement Conferences

A voluntary settlement conference is a proceeding before an administrative law judge held in cases where the employer/insurer has filed a Form WC-1-EDI FROI or the employee has initiated a case through the DMU or it may be set by written request of a party by completing Form WC-182 Request for Voluntary Settlement Conference, or it may be set at the discretion of the Division. Form WC-159 Notice of Voluntary Settlement Conference is sent to the parties.

Conferences will be set within one hundred twenty (120) days after the local adjudication office receives the request. If the request is received too late to be set on a docket scheduled within one hundred twenty (120) days or if no dockets are scheduled in that docket location for one hundred twenty (120) days, the case shall be set on the next available docket.

Continuances will be allowed to accommodate the needs of the parties and the status of the case. A request for a continuance submitted prior to the docket date should be in writing. When a claim is filed and the case is tickled or docketed for a conference setting, the tickler or docket setting is automatically cancelled. The case is automatically tickled for a pre-hearing from the filing of the claim.

Pre-hearing

A pre-hearing is a proceeding before an administrative law judge to discuss issues in a case in which a Form WC-21 Claim for Compensation or claim has been filed. A pre-hearing may be requested by completing Form WC-183 Request for Pre-Hearing. Form WC-163 Notice of Pre-hearings is sent to all parties.

A party may request a pre-hearing by completing Form WC-183 Request for Pre-Hearing when:

1. The parties want to present a settlement agreement for approval; or
2. Disputes or other issues arise that must be resolved in order for the case to proceed; or
3. The parties have a good faith belief that a brief meeting with an administrative law judge will help in moving the case more expeditiously to settlement or final hearing.

A party requesting a pre-hearing is not required to have a medical report. Medical reports, if available, may be exchanged at or before this docket setting. The pre-hearing may be helpful in determining what type of medical and non-medical evidence is necessary to resolve any issues or disputes.

Pre-hearings will be set within one hundred twenty (120) days after the local adjudication office receives the Form WC-183 Request for Pre-Hearing. If the request is received too late to be set on a docket scheduled within the one hundred twenty (120) days or if no dockets are scheduled in that docket location for one hundred twenty (120) days, the case shall be set on the next available docket.

Continuances are allowed to accommodate the needs of the parties and the status of the case. Requests for continuances must be in writing and filed with the local adjudication office. Multiple pre-hearings may be scheduled in a case at the discretion of the administrative law judge assigned to the file.

Mediation

A mediation is a setting in which the parties and their attorneys, if represented, meet with an administrative law judge to discuss issues in a confidential manner, identify areas of agreement and facilitate a compromise settlement of a claim to avoid proceeding to a hearing.

A mediation may be set upon the written request of a party by completing Form WC-184 Request for Mediation, provided that an administrative law judge finds that the issues have been sufficiently developed to make the mediation meaningful. It is the intent of the Division to conduct a mediation before the parties incur the expense of any expert medical depositions.

If a request for mediation is approved, it will be set within one hundred twenty (120) days after the local adjudication office receives Form WC-184 Request for Mediation. If the request is received too late to be set on a docket scheduled within the one hundred twenty (120) days or if no dockets are scheduled in that docket location for one hundred twenty (120) days, the case shall be set on the next available docket. Form WC-162 Notice of Mediation is sent to the parties.

The parties shall engage in meaningful negotiations, in an attempt to resolve disputes on their own prior to requesting mediation. A party may file a written request for a mediation, by completing and filing Form WC-184 Request for Mediation at a docket setting.

A party may request a mediation when:

1. There are issues that need to be resolved to move the case forward.
2. One party has a final rating report and the opposing party has not, within a reasonable time frame, obtained a final rating report;
3. Both parties have exchanged final reports, but the parties have been unable to reach a settlement agreement;
4. Initial or additional medical treatment has been:
   1. Requested by the employee;
   2. Refused by the employer; and
   3. The employee has written medical evidence establishing the need for treatment and the relation between the alleged job-related injury and treatment prescribed. This type of request is automatically considered a hardship request; or
5. Parties have been unable to resolve a Second Injury Fund claim and the employee possesses written medical reports or other records or reports relating to the claim.

All parties shall be present at all scheduled mediations in person or by attorney. Each party must have a person with authority to settle the case either present at the mediation or immediately available by telephone. The employee and employer should be encouraged to appear for the mediation. At a mediation, all attorneys are expected to know the issues, the facts, and the law applicable to their case. They are also expected to have with them the written evidence upon which they intend to rely at the hearing.

All parties shall submit copies to the administrative law judge conducting the mediation of all relevant medical records and reports and any other documents to explain or determine disputed factual and legal issues.

All documents and notes of the administrative law judge from a mediation are confidential. See 8 CSR 50-2.050. No information from the mediation shall be entered in a minute entry except the fact that the mediation was held, the parties in attendance, and any disputed issues that were not resolved

If the mediation does not result in a settlement, the administrative law judge who conducted the mediation may be disqualified from conducting an evidentiary hearing in the case upon written application of any party under Section 287.460, RSMo. The requesting party does not lose its right to an automatic change of judge under Section 287.810, RSMo. When possible, a different administrative law judge should be assigned to conduct any subsequent hearing regardless of whether such a request is made or not. An administrative law judge can hold additional mediations in the same case if circumstances so dictate.

Hardship Hearings including Section 287.203 Hearings

A hardship hearing is an evidentiary hearing held before an administrative law judge when the employee alleges that he or she is not at maximum medical improvement, is in need of medical treatment or entitled to temporary total disability benefits, and the employer is not providing such treatment or benefits. The hearing may alternatively be based on the termination of benefits under Section 287.203, RSMo. A hardship hearing is a hearing in which the employee is requesting the issuance of a temporary or partial award. A temporary or partial award addresses issues of medical treatment and payment of temporary disability benefits. If a party requests the issuance of a final award and makes it an issue at the hearing, and the evidence presented so merits, a final award may be issued.

The employee must have filed a Form WC-21 Claim for Compensation. The employee may file Form WC-185 Request for Hardship Hearing and/or Section 287.203 RSMo Hardship Hearing. A copy of the request must be sent simultaneously to all other parties. Requests should be sent to the local office that has venue of the case.

A hardship hearing may be requested by completing Form WC-185 Request for Hardship Hearing and/or Section 287.203 RSMo Hardship Hearing if:

1. The employee has not reached maximum medical improvement and initial or additional medical treatment or temporary total disability benefits, or both, have been:
   1. Requested by the employee; and
   2. Refused by the employer; and
   3. The employee has written medical evidence establishing the need for treatment and the relation between the alleged job-related injury and treatment prescribed; or
2. The employee requests a hardship hearing under Section 287.203, RSMo.

When Form WC-185 Request for Hardship Hearing and/or Section 287.203 RSMo Hardship Hearing is received, an administrative law judge shall review the request. Upon review, the administrative law judge may:

1. Require a conference call prior to the setting of an evidentiary hearing;
   1. It is the responsibility of the party requesting the hearing to arrange a conference call with all of the parties and the administrative law judge; and
   2. A party may schedule this call with the docket clerk or the administrative law judge, according to local office procedures.
2. Set the matter for evidentiary hearing;
   1. A Section 287.203, RSMo, hearing must be set within sixty (60) days of the request;
   2. A continuance will not be granted except upon showing of good case or by consent by the parties; or

The purpose of the conference call is twofold. The first is to discuss the merits of the hardship request and to determine if the matter can be settled; and the second is to schedule a hearing date, if necessary. Parties must be prepared to discuss available dates during the call.

All parties must appear at the hearing at the date, time, and place set, and be ready to proceed with the presentation of evidence on all issues.

An administrative law judge may grant a continuance of the hardship hearing only upon a showing of good cause or by consent of the parties. A continuance will not be granted for conflicts after the attorney has cleared the date in advance. The chief administrative law judge must routinely keep dates available for scheduling hardship hearings. In most instances, a hardship hearing will be set within thirty (30) days of the conference call.

A hardship hearing may be inappropriate if the employee has obtained a final disability rating with a medical opinion from the employee’s health care provider for the issuance of a final award that future medical care is needed.

All evidence introduced at the evidentiary proceeding is reported by a reporter appointed by the Division. If appropriate and in conformity with the evidence presented, a temporary award will be issued. Or, if appropriate and in conformity with the evidence presented, a final award will be issued. All depositions and exhibits must be submitted at the time of the evidentiary hearing, unless the administrative law judge, for good cause, allows additional time for their submission. At the conclusion of the evidence, the administrative law judge may require the parties to submit briefs and proposed awards.

As to a § 287.203 hearing, the administrative law judge shall issue an award, including findings of facts and rulings of law, within thirty (30) days of the date of the hearing.  For all other hearings [except hearings on the medical fee disputes reasonableness cases as set forth in 8 CSR 50-2.030 (1) (J)] an administrative law judge shall issue a written award within ninety (90) days of the last day of the hearing.  The hearing shall be concluded within thirty (30) days of the commencement of the hearing, except in extraordinary circumstances where a lengthy trial or complex issues necessitates a longer time than ninety (90) days.

If the administrative law judge determines that any proceedings have been brought, prosecuted or defended without reasonable grounds, the administrative law judge may assess the whole cost of the proceedings upon the party who brought, prosecuted or defended them. The administrative law judge shall not issue a written award if the case is settled or dismissed after a hearing and before the award is issued.

Final Hearing - Requesting Issuance of a Final Award

A hearing requesting issuance of a final award is an evidentiary hearing held before an administrative law judge. Evidence may be offered, testimony may be taken, and a verbatim record made for the reviewing tribunal. A final hearing may be requested when the employee has reached maximum medical improvement or the case is otherwise ready for final resolution.

The employee must have filed Form WC-21 Claim for Compensation. The employee may file Form WC-186 Request for Hearing-Final Award. A request for a final hearing will be considered by completing Form WC-186 Request for Hearing-Final Award when:

1. The administrative law judge determines that:
   1. The parties have completed discovery;
   2. The parties are prepared to present their evidence at a hearing; or
   3. Upon a showing of good cause, the administrative law judge orders the parties to be ready to present all the evidence on the hearing date; and
2. A copy of the request is sent simultaneously to all other parties.

Any party that objects to a hearing request may file a written objection to hearing request within ten (10) days after the request for hearing is filed. If the request and objection is discussed at a docket setting or a conference call, the administrative law judge may set the case or determine, based on the objection, that the request for hearing is premature. The determination by the administrative law judge shall be recorded as a minute entry.

When Form WC-186 Request for Hearing-Final Award for the issuance of a final award has been received, an administrative law judge shall review the request. Upon review, the administrative law judge may:

1. Require a conference call prior to the setting of an evidentiary hearing;
   1. It is the responsibility of the party requesting the hearing to arrange a conference
   2. Call with all of the parties and the administrative law judge; and
   3. A party may schedule this call with the docket clerk or the administrative law judge, according to local office procedures.
2. Set the matter for evidentiary hearing; or determine based on the objection that the request for hearing is premature. The determination by the administrative law judge shall be recorded as a minute entry.

The administrative law judge shall approve or deny a written request for hearing within twenty (20) working days upon receipt of the request at the local adjudication office having venue over the case.

The date of hearing assigned for each case will be no more than one hundred twenty (120) days after the date that the request for hearing is approved, unless all the parties agree otherwise.

All parties must appear at the hearing at the date, time, and place set and be ready to proceed with the presentation of evidence on all issues. Form WC-161 Notice of Hearing is sent to the parties.

An administrative law judge may grant a continuance of the final hearing only upon a showing of good cause or by consent of the parties. A continuance will not be granted for conflicts after the attorney has cleared the hearing date in advance.

All evidence introduced at the evidentiary proceeding is reported by a reporter appointed by the Division. If appropriate and in conformity with the evidence presented, a final award will be issued. All depositions and exhibits must be submitted at the time of the evidentiary hearing, unless the administrative law judge, for good cause, allows additional time for their submission. At the conclusion of the evidence, the administrative law judge may require the parties to submit briefs or proposed awards.

The hearing shall be concluded within thirty (30) days of the date of the commencement of the hearing, except in extraordinary circumstances where a lengthy trial or complex issues necessitates a longer time. The hearing is considered concluded on the date the parties have submitted the complete evidentiary record or on the date granted by the administrative law judge for submission of additional evidence ends and the parties have failed to submit additional evidence. The time for submission of evidence shall not exceed the time limits established in Section 287.460.1, RSMo.

The administrative law judge shall issue an award, including findings of facts and rulings of law, within ninety (90) days of the last day of the hearing. For all other hearings [except hearings on the medical fee disputes reasonableness cases as set forth in 8 CSR 50-2.030 (1) (J)] an administrative law judge shall issue a written award within ninety (90) days of the last day of the hearing.  The hearing shall be concluded within thirty (30) days of the commencement of the hearing, except in extraordinary circumstances where a lengthy trial or complex issues necessitates a longer time than ninety (90) days.

If the administrative law judge determines that any proceedings have been brought, prosecuted or defended without reasonable grounds, the administrative law judge may assess the whole cost of the proceedings upon the party who brought, prosecuted or defended them. The administrative law judge shall not issue a written award if the case is settled or dismissed after a hearing and before the award is issued.

Stipulations for Compromise Settlement (WC-G-11)

Compromise settlements between the parties are encouraged. A compromise settlement must be approved by an administrative law judge in order to be valid. An administrative law judge shall approve a settlement agreement pursuant to Section 287.390, RSMo as valid and enforceable as long as:

1. The settlement is not the result of undue influence or fraud;
2. The employee fully understands his or her rights and benefits;
3. The employee voluntarily agrees to accept the terms of the agreement; and
4. The settlement is in accordance with the rights of the parties.

All stipulations for compromise settlement submitted for approval shall be accompanied by copies of all available medical rating reports, surgical notes and radiological reports, or progress notes showing a diagnosis, or a statement from the employer/insurer’s attorney indicating that the injury is of such a minor nature that no medical report is necessary.

Stipulations for compromise settlement in an acceptable format may be presented for approval by mail, at walk-in settlement conferences, conferences, pre-hearings, mediations or hearings.

Compromise settlements by mail or compromise settlements otherwise presented without the employee's appearance before an administrative law judge shall only be approved if:

1. An employee pro se’s notarized statement in the stipulation for compromise settlement verifies:
   1. That the employee understands his or her rights;
   2. That the settlement is not the result of undue influence or fraud;
   3. That the settlement is in accordance with the rights of the parties; and
   4. That the employee voluntarily agrees to the settlement;
2. Employee is represented by an attorney who verifies that employee has been advised of his or her rights and recommends approval of the compromise settlement agreement; or
3. Extenuating circumstances are presented which justify the approval of the compromise settlement without the appearance of the employee.

Dismissals

A case where a WC-21 Claim for Compensation has been filed may be dismissed or default judgment issued in the following circumstances:

1. Voluntary Dismissals. - A Claim for Compensation may be voluntarily dismissed by the employee as to any party, or the case as a whole. The Division will mail a signed copy of the Order of Dismissal to the parties to the case by ordinary mail. If the employee is unrepresented the Division will mail a certified copy of the signed Order of Dismissal to the employee.
2. Dismissal for Failure to Prosecute – Cases in which no party has requested a setting in one (1) year, will automatically be set on a dismissal docket. The Claim for Compensation may be dismissed for failure to prosecute if after notice to the parties, the claimant or the claimant’s attorney fails to show good cause as to why the claim should not be dismissed.
   1. The notice shall include the date, time and place of the dismissal docket setting.
   2. The caption of the notice shall read: “Notice to Show Cause Why Claim Should Not Be Dismissed”.
   3. A notice of dismissal setting shall be mailed according to the provisions of Chapter 287 RSMo.
   4. The Division shall send the notice to all parties and attorneys of record.
   5. At the dismissal setting, the employee must demonstrate that the claim should not be dismissed for failure to pursue the claim.
3. Default Hearings and Awards – A case may be set on certified notice for a default judgment hearing upon the request of the employee when the employer/insurer has failed to appear and/or defend the claim. A default award may be entered against any party, upon proper notice and after hearing.
   1. Notice of hearing to the party or parties shall be mailed according to the provisions of Chapter 287 RSMo.
   2. The Division shall send the notice all parties and attorneys of record.
   3. Such a setting may be at the discretion of the administrative law judge.

Continuances may be granted in cases set for dismissal or for a default hearing only in the following circumstances:

1. Upon the appearance of the party to whom the notice was directed and a showing that the case is indeed being prosecuted or defended;
2. Upon agreement of all parties; or
3. By written request for continuance and statement of how the case is being prosecuted or defended, sent to the Division before the setting date, with copies to the opposing parties.

A party may request a continuance from the dismissal docket by mailing or faxing a letter to the Division's office. The letter requesting the continuance should state the current status of the employee's claim, the steps the employee will be taking to prosecute the claim and whether the other parties object to the request.

A party may request a continuance from the default hearing setting by mailing or faxing a letter to the Division's office. The letter requesting the continuance should state the current status of the claim, the steps the employer/insurer will be taking to defend the claim and whether the other parties object to the request.

A request for continuance should be made in writing within thirty (30) days after the notice of dismissal or default hearing is received to allow cancellation notices to be issued. Phone messages will not prevent the case from being dismissed or an award entered by default. Attorneys representing employees should not rely on the attorneys for the employer/insurer or the Second Injury Fund to appear and request a continuance.

For claims that have been on prior dismissal dockets or previously been set for default hearings, the administrative law judge should expect more detailed information regarding the status of the case and a specific time schedule of steps the attorney intends to take to conclude the claim. In some cases, the administrative law judge may require an appearance by all parties in order to develop a schedule for completing the claim. If a party subsequently fails to prosecute the claim in accordance with this schedule the claim may be dismissed or a default award entered.

Awards

There are three types of awards that can be made in a workers’ compensation case.

1. Award on Hearing. This is the final determination by an administrative law judge after a hearing.
2. Temporary or Partial Award. This type of award is made by an administrative law judge after a hearing in cases where the claimant is not receiving medical treatment or lost wage benefits. In these situations, the temporary or partial award is made before issues such as the extent of permanent disability are addressed by the judge. The case is kept open until such time as a final award on permanent disability and additional medical needs are made.
3. Award on Agreed Statement of Facts. With this award eligibility for and amount of benefits are not disputed by the parties. However, there may be a disagreement, for example, on the interpretation of a provision of law relevant to the case or a disagreement as to whether or not the claim was filed in a timely manner. The administrative law judge issues this award just as an Award on Hearing is issued.

Appeals to the Labor and Industrial Relations Commission

Once a written award is made, any party to the case has the right to appeal the decision of the administrative law judge. Appeals are made to the Labor and Industrial Relations Commission.

An application for review must be filed with the Labor and Industrial Relations Commission. The applicant may use MOIC-2567 Application for Review, but is not required to use this form. Written application must contain information as to the case and award that the party wishes reviewed and state the reasons for making the application for a review. An application for review must be signed by the applicant or the applicant’s attorney. When an application is filed on behalf of a corporation, the application must be signed by an attorney licensed in Missouri.

When decisions of administrative law judges are appealed to the Labor and Industrial Relations Commission, the Commission sends a request to the court reporter that took the testimony to prepare a transcript. The court reporter should prepare the transcript and forward the same to the Commission within sixty (60) days or submit a memorandum stating the reason that the transcript has not been submitted within the sixty (60) day period.

In rare cases, the Commission will request the Division to conduct a hearing on remand to take additional evidence. The local office should set the case for hearing expeditiously and only grant continuances for extreme circumstances.

Attorney Withdrawal

Motions for leave to withdraw as attorney for a party shall be made in writing, and shall set forth the factual and legal basis for the requested withdrawal.

Adjudication Forms

WC-182 Request for Voluntary Settlement Conference (AI) Word Version - PDF Version
WC-183 Request for Pre-Hearing (AI) Word Version - PDF Version
WC-184 Request for Mediation (AI) Word Version - PDF Version
WC-185 Request for Hardship Hearing and/or Section 287.203 Hardship Hearing (AI) Word Version - PDF Version
WC-186 Request for Hearing - Final Award (AI) Word Version - PDF Version

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