Strict Compliance Required in Medical Fee Review Procedures

Medical Fee Review is the procedure in Pennsylvania Workers' Compensation to review the amount and/or timeliness of the payment of a work-related medical expense.

Utilization Review is the procedure to challenge the reasonableness and necessity of a work-related medical expense.

Denial of a Medical Bill is the proper method to challenge the "work-relation" or causal relationship of the medical expense to the accepted work injury.

Downcoding occurs when an insurer changes a CPT code (Current Procedural Terminology) submitted by the healthcare provider. The procedure is set out at Regulation 127.207.

Medical Fee Review Procedure
Medical Fee Review is initiated by the filing of a form, LIBC-507, Application for Fee Review Pursuant to Section 306 (f.1) with the Bureau of Workers' Compensation. This Application must be filed within 30 days of notification of a dispute regarding the bill OR within 90 days of the following the original billing date, whichever is later. [ See: Regulation 127.252].

The Bureau of Workers' Compensation performs an initial Administrative review, within 30 days of receipt of all necessary documents
If a party is unsatisfied with the result, an "appeal" may be filed within 30 days of the administrative determination.
The Bureau will assign the request for hearing to a Hearing Officer (HO) to conduct a de novo hearing.
The HO will issue a decision within 90 days of the close of the record.
Any further appeal may be filed with the Commonwealth Court.

Strict compliance with the Medical Fee review procedures has been required.

Witkin v. Bureau of Workers' Compensation Fee Review Hearing Office (SWIF),
a reported decision of a panel of the Commonwealth Court of Pennsylvania authored by Judge McCullough on April 17, 2013 reviewed this procedural issue.

The treatment under review was the "notorious" TMR Therapeutic Magnetic Resonance treatment.
TMR is said to use magnets to reorganize scattered molecules in a painful region and ostensibly reduce pain.

Factual and Procedural Background

In the past, the Fee Review office has addressed the issue of correct code and reimbursement rate for TMR treatments.

In the instant case, Provider Witkin submitted invoices for TMR treatment billed at $3,298.00 per treatment under CPT code 76498 (generally used to identify magnetic resonance procedures).

SWIF downcoded the procedure to CPT code 97032  and paid $26.24 per treatment.

Witkin filed two Fee Review Applications.
After Administrative Review, the Fee Review office concluded that SWIF properly reimbursed the provider.
Witkin appealed this administrative determination.
A Hearing Officer (HO) was assigned to the appeal.

Without conducting a hearing the HO conducted a de novo review (sic) and issued a decision stating that the issue of coding for TMR has been "fully litigated" in the past and the proper CPT code for TMR treatment is 97032. The HO found no basis for the Provider to have a "second chance" to litigate the correct code.

Commonwealth Court Decision

The Provider Fee Review Applications were remanded for a hearing.
[SWIF did not oppose the Provider's request to reverse the HO decision and remand this matter for a full hearing on the merits].

The HO must first determine that SWIF strictly adhered to the downcoding procedures mandated by Section 127.207 of the Regulations and the prior decision at Liberty Mutual v. Bureau of Workers' Compensation (Kepko) 37 A.3d 1264 (Pa. Cmwlth 2012, appeal denied 53 A.3d 51 (Pa. 2012).

If the Insurer does not strictly comply with the procedure, the provider is entitled to reimbursement for the actual charges. Liberty Mutual, 37 A.3d at 1270.

In Witkin, the HO concluded the provider was barred from "relitigating" the proper CPT code, without conducting a hearing to determine if insurer SWIF complied with the downcoding regulations.

"A prior determination of the proper CPT code for TMR treatment is immaterial until the issue of whether SWIF strictly complied with the Regulations is decided."  slip opinion at page 5.

Practice Pointers:

1. The Fee amounts involved in this dispute demonstrate the importance of employing a knowledgeable and experienced medical bill re-pricing employee or vendor. The difference in reimbursement for two treatments was $52.48 versus $6,596.00, a significant difference!

 2. Proactively review medical expense billing statements. In many work comp cases the payments for medical expenses may exceed the payment of wage loss benefits.  The Pennsylvania Workers' Compensation Act was amended in 1993 and 1996 to provide Employers and Insurers with remedies to review and maintain some degree of control over medical expenses.

Be proactive, use these procedures and remedies!!!