33 A.3d 691
Pa. Commw. Ct.2011Background
- Work-related back injury of 72-year-old Claimant; EMS transported to Hospital, an accredited level I trauma center.
- Claimant diagnosed with two unstable spinal fractures; admitted as trauma patient and placed in Trauma-Neuro ICU; underwent spinal surgery two days later.
- Provider billed $406,338.79; Employer paid $142,196.00 and issued an EOB disputing the remainder.
- Provider timely filed a fee review; Bureau ordered full payment; Employer appealed to Fee Review Hearing Office.
- Hearing Officer found trauma-center exemption applied under 34 Pa.Code § 127.128; Employer argues untimeliness, no immediate life-threatening injuries, and due process issue.
- Employer contends testimony by Employer’s physician by telephone was improperly precluded; Provider presented testimony from its own physicians and financial director.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Timeliness of fee review filing | Employer argues filing was untimely under 90 days from billing date. | Provider argues EOB notice triggered 30-day window; timely filing. | Timely; filing within 30 days of disputed treatment notice. |
| Trauma center exemption applicability | Claimant did not meet immediately life-threatening/urgent criteria at initial assessment. | EMS transported per ACS Step Four and subsequent inpatient care supports exemption; ongoing trauma status. | Exemption applies; Provider entitled to 100% of charges. |
| Due process and telephone testimony | Employer was denied opportunity to present telephone testimony by treating physician. | Hearing Officer acted within rules; pre-hearing notice did not identify the witness timely. | No due process violation; denial proper given pre-hearing identification. |
Key Cases Cited
- Temple University Hospital v. Department of Labor and Industry, 873 A.2d 780 (Pa.Cmwlth.2005) (timing of fee review when initial bill and audit create disputed treatment)
- Thomas Jefferson University Hospital v. Bureau of Workers' Compensation Medical Fee Review Hearing Office, 794 A.2d 933 (Pa.Cmwlth.2002) (when insurer dispute is absent, 30-day window may be inapplicable)
- Laundry Owners Mutual Liability Insurance Association v. Bureau of Workers' Compensation (UPMC), 853 A.2d 1130 (Pa.Cmwlth.2004) (trauma exemption ends when discharged to non-acute facility if continued stay is not for acute care)
- Pittsburgh Mercy Health Sys. v. Bureau of Workers' Comp. Fee Review Hearing Office, 980 A.2d 181 (Pa.Cmwlth.2009) (explanation of review as notification of disputed treatment for fee review timing)
- Capital BlueCross v. Pa. Ins. Dep't, 937 A.2d 552 (Pa.Cmwlth.2007) (agency discretion in evidentiary rulings in fee review)
- Burch v. Dep't of Pub. Welfare, 815 A.2d 1143 (Pa.Cmwlth.2003) (due process requires notice and opportunity to be heard, not absolute right to be heard)
- Pa. Sav. Ass'n v. Dep't of Banking, 523 A.2d 837 (Pa.Cmwlth.1987) (proper exercise of agency discretion in hearing contexts)