Tuesday, February 11, 2014

The Limited Scope of Medical Fee Review Proceedings - Selective Insurance Co. revisited

The Limited Scope of Medical Fee Review Proceedings.

On December 6, 2013, the Commonwealth Court of Pennsylvania issued an opinion and order in an insurer's appeal, in a Medical Fee Review Petition reported at:
Selective Insurance Company of America v. Bureau of Workers' Compensation Fee Review Hearing Office (The Physical Therapy Institute).
[blog entry December 31, 2013].

The December 6, 2013 opinion concluded that a Medical Fee Review Request is not the appropriate forum to litigate and to determine if a billing company, such as "PTI" a/k/a/ the Physical Therapy Institute, is a medical services "provider", for the purpose of workers' compensation reimbursements and medical fee review remedies.

The Commonwealth Court held that the issue of whether PTI is a "provider" of physical therapy is beyond the scope and jurisdiction of these administrative fee review proceedings. The Fee Review is a simple process with a narrow scope, dealing with the issues of the timeliness or correctness of the amount of reimbursement paid.

The issue of whether PTI is a "provider" entitled to any reimbursement, is a complex issue for a Workers' Compensation Judge to decide. As the Bureau did not have jurisdiction, the Fee Review Determinations were vacated.

The Commonwealth Court granted the PTI Request for Reargument and withdrew the December 6, 2013 opinion and order.

HOWEVER, when the Commonwealth Court issued its final decision on February 4, 2014, the opinion was identical, but for the addition of footnote #9.

Footnote #9 addressed the argument of PTI, that the provider's only recourse is to file a Medical Fee Review Request, as a provider cannot file other types of petitions. Without a Medical Fee Review remedy, the provider would be without any appropriate work comp remedy.

In response, the Court noted that the Work Comp Claimant will often file a petition for Review and/or Penalty, in order to raise the issue of medical expense reimbursements and Employer/Insurer liability to pay.
The Court referenced other known instances where claimants filed a petition to litigate the instant issue of PTI's status as a provider.

The absence of a direct statutory remedy for providers does not mean the Court may expand the scope of review to create a remedy. That is a matter for the legislature.


1. Have an experienced Work Comp Professional review medical billing statements for the presence of any legal argument regarding the "status" of the billing company as a "provider" within the intent and meaning of the Work Comp Act. 

2. Perform a cost - benefit analysis... is the amount in controversy sufficient to justify the time and expense of litigation... is it a recurring charge ... is there a significant difference between the Medicare A and Medicare B reimbursement rates?

 In Selective, the bills involved were $2,080 and $810. I would hazard a guess that these are recurring expenses, justifying this review and challenge.

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