Laundry Owners Mutual Liability Insurance Ass'n v. Bureau of Workers' Compensation

853 A.2d 1130, 2004 Pa. Commw. LEXIS 529
CourtCommonwealth Court of Pennsylvania
DecidedJuly 14, 2004
StatusPublished
Cited by10 cases

This text of 853 A.2d 1130 (Laundry Owners Mutual Liability Insurance Ass'n v. Bureau of Workers' Compensation) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Laundry Owners Mutual Liability Insurance Ass'n v. Bureau of Workers' Compensation, 853 A.2d 1130, 2004 Pa. Commw. LEXIS 529 (Pa. Ct. App. 2004).

Opinion

OPINION BY

Senior Judge JIULIANTE.

Laundry Owners Mutual Liability Insurance Association (Insurer) petitions for review of the July 31, 2003 order of the Bureau of Workers’ Compensation Fee Review Hearing Office (FRHO) that granted two fee review applications on behalf of UPMC Presbyterian (Provider) and awarded Provider payment of $60,795.04 with interest for a remaining unpaid charge for medical services rendered to Nelson Smolter (Claimant) for the period of March 17 through April 2, 2001, in accordance with the provisions of Section 306(f.l)(10) of the Workers’ Compensation Act (Act). 1 We affirm in part, reverse in part and remand for a recalculation of the amount of Provider’s fee to be paid by Insurer.

The FRHO’s Hearing Officer found the following facts. On March 12, 2001, *1132 Claimant sustained multiple injuries in a head-on motor vehicle accident and was admitted to Provider’s facility via the emergency department. Also on March 12, 2001, Claimant underwent multiple surgical procedures to repair his injuries, which included multiple fractures of the arms, legs and hip. On March 14 and 16, 2001, Claimant underwent similar surgical procedures. Finally, on March 21, 2001, Claimant underwent a limb salvage operation described as a “flap procedure.” Following the flap procedure, Claimant received post-operative care until his transfer on April 2, 2001.

Provider billed Insurer for the services rendered to Claimant during the period of March 12 through April 2, 2001 using a required health insurance claim. Provider’s claim reported a total charge of $229,686.75 and indicated Provider’s status as a Level I trauma center. Provider also submitted an itemized billing statement in support of its total charge.

In response, Insurer through its repri-cer, advised Provider via an Inpatient Explanation of Benefits (IEOB), dated June 4, 2001, that Provider’s bill was payable at 100% of the allowable charge for the dates of March 12 through 16, 2001 and that a total charge of $159,040.50 was identified for those five days. A second IEOB, also dated June 4, 2001, separately.identified a total charge amount of $70,646.25 for the period of March 17 through April 2, 2001 and indicated a “total Act 44 amount” 2 of $9,851.21. Insurer also issued a June 5, 2001 IEOB summarizing the amounts mentioned.

Provider subsequently submitted two fee review applications to the Fee Review Section of the Bureau of Workers’ Compensation (Bureau). In Application No. 11971, Provider sought review of the timeliness of payment by Insurer for Provider’s bill for service provided to Claimant from March 12 through April 2, 2001. In Application No. 12739, Provider sought review of both the amount and timeliness of payment regarding the same bill.

On August 6, 2001, the Bureau issued administrative decisions granting Provider additional payment of $60,795.04 and interest thereon with regard to the bill submitted. Insurer timely filed a request for a fee review hearing with the FRHO. With regard to both of Provider’s applications, Insurer asserted that after the first five days, Provider was not providing acute care to a patient with an immediately life-threatening or urgent injury as required by Section 306(f.l)(10) of the Act. Thus, Insurer maintained that the amount it paid was appropriate.

An FRHO hearing was held on August 28, 2002 at which both parties presented evidence. Insurer presented the testimony of Dean Meixner, a claims adjuster, and introduced the deposition testimony of Dr. John Nolan, a board-certified orthopedic surgeon who reviewed the 400-page record in the case.

Provider presented the testimony of Dr. Robert Goitz, an attending orthopedic surgeon in the case, and Dr. Gary Gruen, a board-certified plastic surgeon who is on the Board of Directors of the Pennsylvania Trauma Systems Foundation. Although not involved in Claimant’s care, Dr. Gruen also reviewed the extensive case record.

Dr. Goitz opined that Claimant was suffering from a life-threatening condition until March 28, 2001, at which time he was ready for discharge to a rehabilitation facility. The doctor, however, noted in Claimant’s discharge summary report that *1133 Claimant’s discharge was delayed due to insurance reasons. The Hearing Officer found Dr. Goitz’s testimony to be credible and accepted it as fact.

Dr. Gruen also testified that Claimant had a life and limb threatening condition and was not an appropriate candidate for transfer until March 28, 2001. The doctor further testified that as of March 28, 2001, Claimant was stable for discharge and did not need acute care guidelines. " The Hearing Officer also found Dr. Gruen’s testimony to be credible and accepted it as fact.

Dr. Nolan, Insurer’s medical witness, testified that Claimant’s injuries were immediately life threatening or urgent up until March 19, 2001, when Claimant’s flap procedure was delayed because he was bumped by another patient needing surgery. However, Dr. Nolan did not feel that Claimant could be transferred to another facility until March 28, 2001. Noting Dr. Nolan’s lack of specialized training and experience with extremity injuries and microsurgery, the Hearing Officer found Dr. Nolan’s testimony not credible to the extent it conflicted with that of Drs. Goitz and Gruen.

Meixner, a claims adjuster for Insurer since 1991, stated that in determining the appropriate level of reimbursement in this case, his primary focus in reviewing the records was to ascertain the period of time that Claimant’s treatment represented life-threatening and urgent care. Meixner determined that Claimant’s condition became non-life-threatening after the first five days of admission. Noting Meixnér’s lack of any medical degree or substantial medical education in trauma matters, the Hearing Officer found Meixner’s testimony not credible to the extent that it conflicted with that of Drs. Goitz and Gruen.

Turning to the Act, the Hearing Officer initially noted generally that pursuant to Section 306(f.l)(3)(i) of the Act, 77 P.S. § 531(3)(i), a health care provider shall not accept payment for treatment or service rendered in excess of 113% of the applicable Medicare reimbursement rate for said treatment or services. The Hearing Officer then cited Section 306(f.l)(10) of the Act, which provides for payment of the usual and customary charge if acute care is provided to a patient with an immediately life-threatening or urgent injury by a Level I or Level II trauma center accredited by the Pennsylvania Trauma Systems Foundation.

The Hearing Officer next cited Section 109 of the Act, 77 P.S. § 29, which provides that the term life-threatening injury “shall be defined by the American College of Surgeons’ [ACS’] triage guidelines regarding use of trauma centers for the region where the services are provided.” 3

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Bluebook (online)
853 A.2d 1130, 2004 Pa. Commw. LEXIS 529, Counsel Stack Legal Research, https://law.counselstack.com/opinion/laundry-owners-mutual-liability-insurance-assn-v-bureau-of-workers-pacommwct-2004.