Denying Medical Bills: New Guidance From the Courts or More Confusion? | Chicago Popular

Rate review is a small but growing area of ​​workers’ compensation law. Providers and insurers are given a separate arena to address disputes over the amount and timeliness of medical bills. In recent years, Pennsylvania appellate courts have handed down a series of rulings that, when taken together, have expanded vendors’ rights in the rate review process, yielding confusing results.

In First workers pharmacy. Servs., LLC v. BWC Fee Review Hearing Officethe Commonwealth Court [1] addressed a new argument raised by providers. You can see a complete analysis of this case herebut simply put, the case grappled with how and when an insurer can deny medical bills.

In Before the workers, there was a confirmed injury to the right shoulder. The complainant received a prescription for a topical cream and the pharmacy invoice was presented to the courier for payment. Notably, the billing submission did not contain any record showing that the drug was related to the work injury. As a result, the carrier denied the same. The provider has appealed through the fare review setting.

In a surprising decision, the Commonwealth Court held that because there was recognized harm, the carrier was obliged to apply for review of the use of the treatment Before could deny the payment of the bill. This has come as quite a shock to workers’ compensation professionals. Setting aside the expense and logistics involved in this ruling, the decision directly contradicts the statute and long-standing precedent.

The workers’ compensation rules explicitly state that the use review process “cannot” address the causal link between medical treatment and an occupational injury.[2] Additionally, there is long-standing precedent from Pennsylvania courts upholding this restriction on the usage review process. [3] The First Workers’ Court has attempted to square this circle by arguing that questions of causality can, in fact, be addressed in the use review process because if the treatment is unrelated…”a fortiori it is not reasonable or necessary for the accepted wok bias. Id., at 621. [4]

This left the carriers in a difficult position. Based on Before the workersmany carriers wondered whether to apply for usage review for everything treatment before denying medical bills. This process is expensive and time consuming. Carriers receive thousands in medical bills every single day; it’s simply not practical to go through every bill through the usage review process.

In a recent decision, the Commonwealth Court appears to have addressed these concerns. Unfortunately, questions remain.

In Skay vs. Borjeson & Maizel LLC (WCAB) [5], the court considered a situation similar to that of the Workers’ First case. Here, the plaintiff had an accepted work accident. Previous usage reviews from 2015 and 2017 were conducted and found some medications to be reasonable and necessary. Years later, the carrier denied payment for those same drugs on the grounds that the treatment was unrelated to the work injury. In the subsequent criminal petition, the carrier argued that there was no evidence to show that the drugs were related to the work injury. The appellant, for reasons unknown, did not submit any medical evidence to address the causal link. Rather, it relied solely on previous usage reviews and argued that the processing was already deemed reasonable and necessary, and as such, the carrier was responsible for it.

On appeal, the Commonwealth Court rejected this argument. The court noted that the plaintiff bears the burden in a criminal petition. Furthermore, the court cited pre-Before the workers case law to hold that the use review process does not “establish a causal link between a medical condition and the applicant’s work injury”. [6] The court also cited the law in question, noting that the use review’s determinations do not decide the causal link between the treatments in question and the workplace injury. [7] As the applicant did not submit any medical evidence to establish causation, the carrier was not responsible for the treatment and the fine application was dismissed.

At first glance, this case appears to rectify the confusion Before the workers. The law on causation and use control has returned to itsBefore the workers status quo. Unfortunately, the Skay decision does not mention the Before the workers case nor refer to ‘a fortiori‘ argument he established. As a result, the court likely created two different standards for denying medical bills: one for the rate review setting, where a review of prior use is required, and another for traditional workers’ compensation litigation, where it is not. If there are Two standard, then below Skay, an insurer may legitimately deny a bill as unrelated, succeed in litigation in a workers’ compensation court, but still be held liable for that payment if the provider then files an application for a rate revision. This seems unreasonable.

It is this author’s opinion that the court did not intend to create two standards for the processing of medical bills. Rather, Skay’s most practical interpretation is the simplest: the usage review does not address causation. SkayWhether intentional or not, it reduces the scope of the rate review process to its original purpose, which is to address only the amount and timeliness of a medical bill without relying on usage review. With all that said, more controversy is likely to arise around this issue. Carriers are therefore advised to review their medical billing processes with legal counsel.

[1] 225A.3d 613 (Pa.Cmwlth. 2020).

[2] 34 Pa. Code. § 127.406(b)(1).

[3] See, Hoffmaster vs. WCAB (Senco Products, Inc.)721 A.2sd 1152 (Pa.Cmwlth. 1998).

[4] This reasoning was later incorporated into a widespread decision a few months later Before the workers. See, Omni Pham. Services. LLC vs. BWC, Fee Review Hearing Office (Am. Interstate Ins. Co.), 241 A.3d 1273 (Pa.Cmwlth. 2020).

[5] 280 A.3d 19 (Pa.Cmwlth. 2022).

[6] See, 280A.3d at 22; See also, Security Section Services. USA, Inc. v. WCAB (Schuh)16 A.3d 1221, 1224 (Pa.Cmwlth.2011).

[7] id.; See also34 Pa. Code. §127.406(b)(1).


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Written by Natalia Chi

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