Physical Therapy Institute, Inc. v. Bureau of Workers' Compensation Fee Review Hearing Office

108 A.3d 957, 2015 Pa. Commw. LEXIS 38
CourtCommonwealth Court of Pennsylvania
DecidedJanuary 16, 2015
StatusPublished
Cited by6 cases

This text of 108 A.3d 957 (Physical Therapy Institute, Inc. v. Bureau of Workers' Compensation Fee Review Hearing Office) 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
Physical Therapy Institute, Inc. v. Bureau of Workers' Compensation Fee Review Hearing Office, 108 A.3d 957, 2015 Pa. Commw. LEXIS 38 (Pa. Ct. App. 2015).

Opinion

OPINION BY

Judge LEAVITT.

Physical Therapy Institute, Inc. petitions for review of an adjudication of the [958]*958Bureau of Workers’ Compensation Fee Review Hearing Office (Bureau) dismissing the request of Selective Insurance Company of SC (Insurer) for a hearing to contest fee review determinations made by the Bureau’s Medical Fee Review Section. Insurer asserted that it did not have liability for invoices issued by an entity that was not the provider of medical treatment to a claimant. The Bureau held that it lacked subject matter jurisdiction over Insurer’s request for a hearing. Nevertheless, the Bureau vacated the fee review determinations challenged by Insurer on grounds that the Bureau’s Medical Fee Review Section lacked authority to consider the applications. Physical Therapy Institute has appealed the Bureau’s vacating of the fee review determinations. We affirm.

On August 16, 2012, Timothy Aston (Claimant) injured his low back while working for Greensburg Beverage, Inc., for which he was prescribed physical therapy. Insurer denied Physical Therapy Institute’s invoices for this treatment for the stated reason that it did not actually provide physical therapy to Claimant, explaining as follows:

The billing entity, the Physical Therapy Institute, did not provide the injured worker with the physical therapy services for which payment is sought. The services were provided by a Medicare Part B provider. Its level of reimbursement is much lower than that of [Physical Therapy Institute], a Medicare Part A provider. The Part B provider has not submitted a bill for consideration. Under the PA [Workers’ Compensation] Act,[1] the amount of payment owed to the Physical Therapy Institute is $0.00.

Reproduced Record at 230a, 269a, 801a, 832a, 366a (R.R.-).

Physical Therapy Institute filed five separate fee review applications, requesting review of the “amount of payment.” R.R. 223a, 264a, 296a, 327a, 359a. Its first application related to treatment provided from September 4, 2012, to September 21, 2012, for which it billed $4,042.38. The second application related to treatment provided from September 24, 2012, to September 27, 2012, for which it billed $1,816.29. The third application related to treatment provided on October 15, 2012, for which it billed $537.12. The fourth application related to treatment provided from December 17, 2012, to January 3, 2013, for which it billed $3,417.31. The Bureau’s Medical Fee Review Section ordered full payment on all these invoices plus ten percent interest. The fifth application related to treatment provided from January 7, 2013, to January 14, 2013, for which Physical Therapy Institute billed $2,330.12. The Bureau’s Medical Fee Review Section reduced this invoice to $2,219.36 and ordered its payment plus ten percent interest.

Insurer then filed a “Request for Hearing to Contest Fee Review Determination,” seeking a de novo hearing on all five determinations. R.R. la-8a. Insurer identified the issue as whether a Medicare Part B provider may contract with a Medicare Part A provider, i.e., Physical Therapy Institute, to use the Medicare Part A provider’s tax identification number in order “to obtain reimbursement at the level of a Medicare Part A provider which is significantly in excess of the level of payment to a Medicare Part B provider.” R.R. 2a, 4a, 6a, 8a.

The matter was assigned to the Bureau’s Hearing Office. At a pre-trial conference, Insurer stated its intention to present witnesses that Physical Therapy [959]*959Institute is not entitled to payment because it did not provide the services for which it was billing. Physical Therapy Institute moved to exclude this proposed evidence as an issue beyond the Bureau’s jurisdiction. The Hearing Officer denied the motion, holding that the Hearing Officer had jurisdiction to decide the identity of the provider that provided services to Claimant.

Insurer took Claimant’s testimony by deposition. Claimant testified that he received physical therapy at a facility called THE pt GROUP. Claimant testified that he never heard of Physical Therapy Institute.

Before the parties finished developing their evidence, this Court issued its decision in Selective Insurance Company of America v. Bureau of Workers’ Compensation Fee Review Hearing Office (The Physical Therapy Institute), 86 A.3d 300 (Pa.Cmwlth.), petition for allowance of appeal denied, — Pa. -, 96 A.3d 1030 (2014), which involved the same parties and nearly identical facts.2 There, we held that the Bureau lacks jurisdiction to determine whether an entity is a “provider” of medical services, or simply a billing agency. This is a question of liability, which is beyond the scope of a fee review and must be decided by a workers’ compensation judge. Id. at 304-05. We also held that the Bureau’s Medical Fee Review Section lacked jurisdiction to consider Physical Therapy Institute’s fee review petitions in the first instance and, therefore, the fee review determinations had to be vacated. Id. at 305.

Observing that this Court’s decision in Selective Insurance is binding precedent, the Hearing Officer in the instant matter dismissed Insurer’s hearing requests for lack of jurisdiction and vacated the Medical Fee Review Section’s fee review determinations. Physical Therapy Institute then petitioned for this Court’s review.3

On appeal, Physical Therapy Institute asserts that the Bureau should not have vacated the Bureau’s fee review determinations that Insurer “was liable to [Physical Therapy Institute] for the amounts billed by the provider, [Physical Therapy Institute],” plus interest. Physical Therapy Institute’s Brief at 8.4 Physical Therapy Institute argues that the Bureau erred. Physical Therapy Institute contends that the applications for fee review were proper because they challenged the amount of payment received from Insurer, namely, $0.00. Physical Therapy Institute argues that this was the only avenue available to Physical Therapy Institute to try to secure payment and that Insurer should not be permitted to derail the fee review process with its allegations of fraud. Physical Therapy Institute posits that if this Court reaffirms the holding of Selective Insur[960]*960ance, 86 A.3d 300, ie., that the issue raised was non-cognizable in the first instance, insurers will refuse to pay bills and then simply fabricate an unfounded factual or legal issue, leaving providers with no recourse or remedy.5 Providers lack standing to file a review petition or penalty petition for consideration by a workers’ compensation judge.

Insurer rejoins that the Bureau correctly vacated the Bureau’s determinations based on the holding in Selective Insurance, which is binding on the Bureau. Insurer points out that it cannot be ordered to pay Physical Therapy Institute but left without a de novo hearing on the Bureau’s decisions on the applications. We agree with Insurer.

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Bluebook (online)
108 A.3d 957, 2015 Pa. Commw. LEXIS 38, Counsel Stack Legal Research, https://law.counselstack.com/opinion/physical-therapy-institute-inc-v-bureau-of-workers-compensation-fee-pacommwct-2015.