Keystone Rx v. Bur. of W.C., Aplt.
28 EAP 2020
| Pa. | Dec 22, 2021Background
- Keystone Rx LLC filled prescriptions for workers’ compensation claimants and sought payment for those services after insurers/employers denied or failed to timely pay.
- The Workers’ Compensation Act’s Utilization Review (UR) process permits an impartial determination of the "reasonableness or necessity" of treatment and provides review rights to parties and health care providers, but does not include non‑treating providers in the UR process.
- Keystone Rx challenged the Bureau of Workers’ Compensation’s Fee Review Hearing Office order (affirmed by the Commonwealth Court) that left non‑treating providers outside the UR process and limited their remedies to payment challenges.
- The Pennsylvania Supreme Court considered whether non‑treating providers have a role in UR, whether due‑process protections attach to payment expectations before a reasonableness determination, and whether courts may create statutory remedies omitted by the legislature.
- The concurring opinion (Wecht, J.), joining the Majority, emphasized judicial deference to legislative policy choices and held that excluding non‑treating providers from UR is a legislative decision, not a matter for judicial re‑writing of the statute.
Issues
| Issue | Keystone Rx's Argument | Bureau/Defendant's Argument | Held |
|---|---|---|---|
| Whether non‑treating providers may participate in Utilization Review | UR should cover non‑treating providers who render services under a physician’s order | UR is limited by the statute to parties/health care providers; non‑treating providers are excluded | Court held legislature did not include non‑treating providers in UR; they have no role in that process |
| Whether Keystone had a protected property interest in payment before a UR determination | Keystone had an expectation of payment for dispensed prescriptions | No protected property interest exists until treatment is deemed reasonable/necessary | Court held no protected property interest; due process does not require more before UR outcome |
| Whether courts may judicially add remedies or procedural participation omitted by the statute | Court should provide a remedy to prevent unfair non‑payment to providers | Courts must defer to the legislature and may not rewrite statutes or engraft omitted procedures | Court refused to create new statutory rights; remedies lie with the legislature |
Key Cases Cited
- Villani v. Seibert, 159 A.3d 478 (Pa. 2016) (acknowledging legislative prerogative in social policy judgments)
- Weaver v. Harpster, 975 A.2d 555 (Pa. 2009) (policy formulation is for the legislature)
- Discovery Charter Sch. v. Sch. Dist. of Phila., 166 A.3d 304 (Pa. 2016) (courts may not augment legislative schemes)
- Parker v. Children’s Hosp. of Phila., 394 A.2d 932 (Pa. 1978) (courts should not substitute their public‑policy judgment for the legislature’s)
- Glancey v. Casey, 288 A.2d 812 (Pa. 1972) (judiciary should not question the wisdom of legislative action)
- Am. Mfrs. Mut. Ins. Co. v. Sullivan, 526 U.S. 40 (U.S. 1999) (due‑process limits on deprivation of protected property interests)