Selective Insurance Co. of America v. Bureau of Workers' Compensation Fee Review Hearing Office
2014 Pa. Commw. LEXIS 97
| Pa. Commw. Ct. | 2014Background
- Claimant sustained a work-related shoulder injury and received physical therapy; The Physical Therapy Institute (PTI) billed for the services.
- Insurer (Selective) refused payment, arguing PTI did not actually provide the therapy and was merely a billing entity (liability dispute).
- PTI filed two fee-review applications; the Bureau’s Medical Fee Review Section ordered Insurer to pay the billed amounts plus interest, finding Insurer’s denials invalid.
- Insurer requested a de novo hearing to contest the fee-review determinations, arguing the threshold question was whether PTI was a “provider” entitled to payment.
- The Bureau dismissed Insurer’s hearing request for lack of jurisdiction over provider-identity/liability questions but left the Medical Fee Review decisions intact; the court granted review.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Bureau/f ee-review hearing officer has jurisdiction to decide if the billing entity is a "provider" (liability) | Fee review must resolve whether PTI is the provider before any payment; if not, amount owed is $0 | Fee review is limited to amount/timeliness; provider-identity/liability is beyond its scope | Bureau lacks jurisdiction to decide provider-identity; liability must be adjudicated by a workers’ compensation judge |
| Whether Medical Fee Review Section’s payment orders should stand when jurisdiction over provider-identity is lacking | If Bureau lacked jurisdiction to hear Insurer’s contest, Medical Fee Review also lacked jurisdiction to order payment and those determinations should be vacated | PTI argued fee review was the proper remedy and Medical Fee Review’s orders were valid | Court modified and vacated the Medical Fee Review Section’s fee determinations for lack of jurisdiction; affirmed dismissal of Insurer’s hearing request otherwise |
Key Cases Cited
- Crozer Chester Med. Ctr. v. Dep’t of Labor & Indus., Bureau of Workers’ Comp., 22 A.3d 189 (Pa. 2011) (fee review has narrow scope limited to amount/timeliness; liability questions belong to workers’ compensation judges)
- Nickel v. Workers’ Comp. Appeal Bd. (Agway Agronomy), 959 A.2d 498 (Pa. Cmwlth. 2008) (fee review presupposes liability has been established)
- Westinghouse Elec. Corp. v. Workers’ Comp. Appeal Bd. (Weaver), 823 A.2d 209 (Pa. Cmwlth. 2003) (penalty for insurer’s failure to pay proper medical provider is payable to the claimant)