Fidelity & Guaranty Insurance Co. v. Bureau of Workers' Compensation
13 A.3d 534
| Pa. Commw. Ct. | 2010Background
- Insurer Fidelity & Guarantee seeks review of a Bureau fee review decision that Provider’s application was timely under 306(f.l)(5) and 34 Pa.Code § 127.252(a).
- Dec. 9, 2006 Claimant injured; Provider treated 12/9–12/19/2006 at trauma center.
- Jan. 18, 2007 Provider billed $104,137.33; Insurer audited and disputed the trauma billing.
- Feb. 21, 2007 Insurer paid $21,327.69 for the disputed period; dispute notification issued Feb. 7, 2007.
- Provider filed Fee Review on the 85th day after billing; Bureau received on 4/13/2007; Bureau issued decision 7/9/2007 granting $82,809.64.
- De novo hearing held 7/22/2008; Hearing Officer found 1/18/2007 billing date and 2/21/2007 dispute date; application timely within 90 days of billing.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether 306(f.l)(5) sets two timing periods for fee review | Fidelity argues 30-day and 90-day periods are separate options. | Insurer contends the 90-day period applies only when no dispute exists. | Two alternative periods may apply: 30 days after dispute or 90 days after billing. |
| Validity of the Regulation adding 'whichever is later' | Regulation expands the statute and is invalid. | Regulation reasonable and within agency authority; not expanding beyond statute. | Regulation valid as legislative rule; consistent with statute and proper procedures. |
| Timeliness of Provider’s Application for Fee Review in this case | Application timely under the 90-day post-billing period. | Insurer disputes payment timeframe and timing of dispute. | Provider’s Application timely within 90 days of original billing date. |
Key Cases Cited
- Harburg Med. Sales Co. v. Bureau of Workers’ Comp. (PMA Ins. Co.), 784 A.2d 866 (Pa.Cmwlth.2001) (two timing tracks for fee review; 30 days after dispute or 90 days after billing)
- Borough of Pottstown v. Pa. Mun. Ret. Bd., 712 A.2d 743 (Pa. 1998) (legislative vs interpretive regulations; proper procedure and reasonableness standard)
- Uniontown Area Sch. Dist. v. Pa. Human Relations Comm’n, 313 A.2d 169 (Pa. 1973) (regulatory authority and reasonableness in regulatory enactments)
- Nationwide Mut. Fire Ins. Co. v. Bureau of Workers' Comp. Fee Review, 981 A.2d 366 (Pa.Cmwlth.2009) (original billing date defined; statutory timing context)
- Seven Stars Farm, Inc. v. Workers’ Comp. Appeal Bd. (Griffiths), 935 A.2d 921 (Pa.Cmwlth.2007) (definition of 'clean bill' and related billing concepts)
- Catholic Health Initiatives v. Heath Family Chiropractic, 720 A.2d 509 (Pa.Cmwlth.1998) (insurer’s payment and timeliness considerations in fee disputes)