Fort Washington Surgery Center v. Indemnity Ins. Co. of N.A. & ESIS, Inc. (Bureau of WC Fee Review Hearing Office), 271 C.D. 2022

The case involves Fort Washington Surgery Center (Provider) seeking review of a decision by the Bureau of Workers’ Compensation's Fee Review Hearing Office regarding payment for ketamine infusions provided to a claimant injured at work.
Provider billed Indemnity Insurance Company of North America and ESIS, Inc. (Insurer/TPA) for 13 dates of service, primarily using three billing codes, with total charges of $90,480.
Of this, Insurer/TPA paid only $28,669.44; Provider claims entitlement to $43,714.56 more (80% of billed charges), citing relevant workers’ compensation regulations for reimbursement of ambulatory surgical centers (ASCs).
Administrative decisions found improper billing on several codes, holding two codes as sequential for the same procedure (not separately billable) and one code (anesthesia) as not independently billable; payment was ordered for only two service dates, with the rest denied.
On appeal, the dispute centered on whether the correct reimbursement standard and data were used in calculating the proper amount owed for procedures not covered by Medicare.
The Commonwealth Court reversed the hearing officer, finding that the wrong data module was used (outpatient instead of ASC rates), and remanded for recalculation and reimbursement under the correct standard.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether correct reimbursement formula under 34 Pa. Code § 127.125 was used for ketamine infusions billed by an ASC	ASC procedures not on Medicare list require 80% of usual/customary charge; correct module not used	Used Fair Health outpatient facility data, not ASC module; used wrong percentile benchmark	Hearing officer used the wrong dataset; remanded for correct ASC calculation
Whether certain codes (96365, 96366, 00600) were properly billed and separately payable	Billed codes represent distinct, separately billable services	Codes are for sequential procedures; anesthesia not separately billable with ketamine infusion	Codes not to be billed separately where duplicative; but payment calculation must use correct ASC standard
Whether hearing officer improperly relied on non-authoritative coding rules (AMA CPT)	CPT guides not referenced in statute/regulation; should not control billing analysis	CPT codes standard for billing analysis	Court did not reach this issue given reversal on other grounds
Whether Insurer/TPA met burden to prove proper reimbursement	Insurer failed to use relevant reimbursement data or prove payments satisfied regulatory standard	Reimbursed at proper (outpatient) percentile rates and data	Insurer/TPA did not meet burden; wrong category used to set payments

Crozer Chester Med. Ctr. v. Bureau of Workers’ Comp., Health Care Servs. Rev. Div., 22 A.3d 189 (Pa. 2011) (fee review process limited to amount/timeliness of payment, not underlying liability)
Catholic Health Initiatives v. Health Fam. Chiropractic, 720 A.2d 509 (Pa. Cmwlth. 1998) (fee review can't address liability or medical necessity; presumes liability is established)