UNIVERSITY PHYSICIANS ASSOCIATES VS. TRANSPORT DRIVERS, INC. (DIVISION OF WORKERS' COMPENSATION), A-3350-15T2

On Oct. 10, 2012, Transport employee Manuel Bonilla was severely injured at work and treated at University Hospital (Level I trauma center). Two surgeons (Drs. Livingston and Adams) provided emergency and operative care and billed at the 95th percentile: Livingston $10,343; Adams $71,374.
Petitioner University Physicians Associates (billing agent for the doctors) sought reimbursement under the NJ Workers' Compensation Act after Transport’s insurer paid at the 75th percentile: $3,688.98 (Livingston) and $24,234.50 (Adams), leaving a disputed balance of $53,793.52.
The Division trial was limited to the usual, customary, and reasonable (UCR) fee determination. Petitioner presented the two treating physicians and its CFO; the judge found their testimony lacking expert billing/market evidence.
Respondent presented Sandra Corradi, a professional coder from a bill-review firm, who testified that insurers routinely pay at the 75th percentile as reflected in FAIR Health data for New Jersey; the judge found her credible.
The judge concluded petitioner failed to prove the billed 95th-percentile fees were usual, customary, and reasonable and dismissed the petition with prejudice. Petitioner appealed.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether petitioner proved its billed 95th-percentile fees were UCR under the Act	Petitioner: trauma services at a Level I center justify payment at the 95th percentile; billed charges should be honored	Respondent: insurer’s 75th-percentile payments reflect industry practice and were supported by FAIR Health data and bill-review expertise	Held: Affirmed — petitioner failed to present persuasive expert/market proof; 75th-percentile payments were reasonable evidence of prevailing fees
Admissibility/weight of witnesses on billing practices	Petitioner: treating physicians and CFO can support customary billing practices	Respondent: need qualified billing/market expert; treating physicians lack coding/market expertise	Held: Judge reasonably discredited petitioner’s witnesses as not expert in billing; credited respondent’s professional coder
Applicability of no-fault trauma exemption to workers’ compensation fee recovery	Petitioner: trauma exemption in no-fault context supports higher (95th) reimbursement for Level I services	Respondent: exemption does not change UCR requirement under Workers’ Comp; fees still must be usual, customary, reasonable	Held: Exemption doesn’t compel 95th-percentile payment; UCR standard governs and insurer may rely on paid-fee data/databases

Sager v. O.A. Peterson Constr., 182 N.J. 156 (standard of review for workers' compensation factual findings)
Close v. Kordulak Bros., 44 N.J. 589 (credibility deference / appellate review framework)
Hersh v. Cty. of Morris, 217 N.J. 236 (appellate review principles)
Mayflower Sec. Co. v. Bureau of Sec., 64 N.J. 85 (de novo review for legal questions)
Brunell v. Wildwood Crest Police Dep't, 176 N.J. 225 (remedial construction of the Act)
Coalition for Quality Health Care v. New Jersey Dept. of Banking & Insurance, 358 N.J. Super. 123 (paid fees better measure than billed fees for prevailing-fee determinations)