Mercy Douglas Corp. v. Workers' Compensation Appeal Board (Davis)

713 A.2d 722, 1998 Pa. Commw. LEXIS 483, 1998 WL 320318
CourtCommonwealth Court of Pennsylvania
DecidedJune 12, 1998
DocketNo. 1846 C.D. 1997
StatusPublished
Cited by4 cases

This text of 713 A.2d 722 (Mercy Douglas Corp. v. Workers' Compensation Appeal Board (Davis)) 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
Mercy Douglas Corp. v. Workers' Compensation Appeal Board (Davis), 713 A.2d 722, 1998 Pa. Commw. LEXIS 483, 1998 WL 320318 (Pa. Ct. App. 1998).

Opinion

SMITH, Judge.

The Mercy Douglas Corporation (Employer) petitions for review of an order of the Workers’ Compensation Appeal Board (Board) that affirmed as modified a decision of a Workers’ Compensation Judge (WCJ) granting Employer’s petitions to terminate compensation benefits and to review medical treatment and/or billing. The Board affirmed the decision as to termination but ordered Employer to pay medical expenses [723]*723for Dolores Davis (Claimant) until the date of the WCJ’s decision. Employer questions whether the Board erroneously ordered it to reimburse Claimant’s medical bills, when payment of such bills was controlled by the utilization review process as set forth in Section 306(f.l) of the Workers’ Compensation Act (Act), Act of June 2, 1915, P.L. 736, as amended, 77 P.S. § 531.1 Claimant has not sought review of the affirmance of the grant of termination; what is at issue here is solely the period during which Employer is required to make payment for Claimant’s medical expenses.

Claimant suffered an injury in the course of her employment on January 4, 1989; she began receiving total disability benefits pursuant to a notice of compensation payable. On May 19,1993, Employer filed a petition to terminate compensation benefits, alleging that Claimant had fully recovered from her work injury on or before March 18, 1993. On February 1, 1994, Employer filed a petition to review medical treatment and/or billing.2 Following hearings in 1993 and 1994 on these consolidated petitions, the WCJ issued a decision on June 19, 1995 concluding that Employer had met its burden of proving that all of Claimant’s disability had ceased as of March 18, 1993. The WCJ concluded further that Employer had established that medical services rendered to Claimant after that date were not reasonable and necessary. The WCJ granted the termination petition; he also granted the review petition and ordered that Employer was not responsible for medical bills after March 18,1993.

On Claimant’s appeal, the Board concluded that substantial evidence of record supported the WCJ’s findings. The Board agreed with Claimant, however, that the WCJ erred by terminating medical benefits as of March 18, 1993. The Board cited Loose v. Workmen’s Compensation Appeal Board (John H. Smith Arco Station), 144 Pa.Cmwlth. 332, 601 A.2d 491 (1991), for the proposition that relief pursuant to a petition to review is prospective only; medical benefits for a com-pensable injury may be terminated pursuant to a review petition only as of the date of the WCJ’s determination that such benefts are unreasonable and unnecessary. The Board therefore modified the WCJ’s order and directed Employer to reimburse Claimant’s medical expenses until June 19, 1995, the date the order was circulated.

Before this Court Employer states that the Board’s reasoning would be sound if the medical treatment at issue were not subject to the utilization review process; however, Employer asserts that it filed an initial request for utilization review pursuant to Section 306(f.l) of the Act in September 1993. The initial determination, contained in a report dated April 21, 1994 and a letter dated May 6, 1994, was that the services were reasonable and necessary until November 17, 1993 but not thereafter, because no improvement was observed in the review chart after that date. Claimant’s request for reconsideration of that determination pursuant to the former version of Section 306(f.l)(6)(ii)3 resulted in a determination that none of the services were reasonable and necessary. The parties agree that Claimant appealed from the adverse utilization review determination, that her appeal was assigned first to the same WCJ involved here and then to another WCJ, who ruled in Employer’s favor, and that Claimant appealed that decision to the Board.4

[724]*724Employer argues that regulations adopted pursuant to Section 306(f.l) relieved it of any duty to make medical payments under the circumstances here. Specifically, 34 Pa.Code § 127.208(a) provides that payments for treatment rendered under the Act shall be made within 30 days of receipt of bills and reports submitted by providers, but § 127.208(e) provides:

The 30-day period in which payments shall be made to the provider may be tolled only if review of the reasonableness or necessity of the treatment is requested during the 30-day period under the UR [Utilization Review] provisions of Subchap-ter C (relating to medical treatment review). The insurer’s right to suspend payment shall continue throughout the UR process. The insurer’s right to suspend payment shall further continue beyond the UR process to a proceeding before a workers’ compensation judge, unless there is a UR determination made that the treatment is reasonable and necessary.

This provision implements Section 306(f.l)(5) of the Act, 77 P.S. § 531(5), which provides in part that all payments to providers must be made within 30 days of receipt of such bills and records “unless the employer or insurer disputes the reasonableness or necessity of the treatment provided pursuant to paragraph (6),” which provides the procedures for utilization review and appeal.

Because Employer had sought utilization review of the treatment provided to Claimant by Dr. Bowden from September 1, 1993 onward, it contends that it was never under any duty to make payments for medical treatments after that date. Employer relies upon Florence Mining Co. v. Workmen’s Compensation Appeal Board (McGinnis), 691 A.2d 984 (Pa.Cmwlth.1997). There also an employer had filed a termination petition and a petition to review medical bills, and during the pendency of that proceeding it filed an initial request for utilization review. The utilization review organization determined that medical treatment in the form of physical therapy was reasonable and necessary up to a certain date but not thereafter. Nether the claimant nor the employer sought further review. The Court held that the effect of the unappealed utilization review determination was to preclude the WCJ and the Board from determining in the. parallel petition proceeding that the employer was liable for certain medical bills incurred after the specified date. From this Employer concludes that the Board here was without authority to order Employer to make payment for medical treatment that was excused by the utilization review process.

Claimant responds that Employer’s reliance upon Florence Mining Co. is misplaced. That case turned on the fact that the utilization review determination had not been appealed and therefore was final. Here, in contrast, Claimant has appealed from the utilization review determinations and that appeal is pending before the Board. Claimant asserts that in a petition to review medical treatment and/or billing pursuant to former Section 306(f)(2)(ii) of the Act, the Employer remains liable to pay medical bills incurred during the pendency of the petition, and any relief granted under this Section is prospective as of the date of the WCJ’s decision, citing Loose, among other eases. She contends that this is the law that the Board applied.

Further, Claimant notes that this Court addressed the relationship between a petition to review medical treatment and a request for utilization review in Bloom v.

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Cite This Page — Counsel Stack

Bluebook (online)
713 A.2d 722, 1998 Pa. Commw. LEXIS 483, 1998 WL 320318, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mercy-douglas-corp-v-workers-compensation-appeal-board-davis-pacommwct-1998.