Court Limits Payments

July 10, 2018

In Sedgwick Claims Management Services v. Bureau of Workers’ Compensation Fee Review Hearing Office, the Commonwealth Court of Pennsylvania examined whether a chiropractor who treated a workers’ compensation claimant is entitled to pay for both the office visits and procedures performed during those visits. According to the Workers’ Compensation Medical Cost Containment Regulation, payments to providers for office visits, in addition to the procedures performed during those visits, are only authorized if the office visit constitutes a significant and separately identifiable service.

The Initial Ruling

Sedgwick argued that the office visits did not constitute a significant and separately identifiable service from the treatments performed, therefore, no additional payment should be required. The Bureau of Workers’ Compensation Fee Review Hearing Office (FRHO) disagreed, finding that Sedgwick was required to pay the chiropractor $78 for each of the 39 office visits, in addition to the treatments performed during those visits. The Hearing Officer found that the insurance administrator failed to prove the meaning of significant and separately identifiable services and failed to show that the value of the office visits was included in the cost of the procedures.

The Findings on Appeal

However, upon appeal, the Commonwealth Court held that the Hearing Officer mistakenly treated the question of what significant and separately identifiable services means. Finding that it rather constitutes a question of law, the Commonwealth Court sought to determine whether payment for same-day examinations was meant to be the exception or the rule. Because significant and separately identifiable services is a language modeled after federal Medicare codes, the Court looked to Medicare case law and administrative decisions for guidance on how to interpret the phrase.

The Court found that the language of the regulation shows the intent to make same-day examination payments the exception to the rule. It also found that, based on interpretation of Medicare case law, examinations involving no new or changed medical condition do not constitute a significant and separately identifiable service.

The Case is Remanded

Noting that the Hearing Officer did not decide whether the examination involved a new or changed medical condition, the Court vacated the order and remanded the case to the Bureau of Workers’ Compensation FRHO for review. The Court refused to dismiss the claims for the office visit charges because there were remaining questions of fact concerning the examinations, the claimant’s medical condition, and the treatments that were provided. Therefore, the Court remanded the case for a determination as to whether the charges were for a new or changed medical condition or another circumstance that went beyond routine evaluations for the treatments performed by the chiropractor.

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