Opinion
No. 614 C.D. 2013
02-04-2014
Selective Insurance Company of SC, Petitioner v. Bureau of Workers' Compensation Fee Review Hearing Office (The Physical Therapy Institute), Respondent
BEFORE: HONORABLE BONNIE BRIGANCE LEADBETTER, Judge HONORABLE MARY HANNAH LEAVITT, Judge HONORABLE ANNE E. COVEY, Judge
OPINION NOT REPORTED
MEMORANDUM OPINION BY JUDGE LEAVITT
Selective Insurance Company of SC (Insurer) petitions for review of an adjudication of the Bureau of Workers' Compensation Fee Review Hearing Office (Bureau) dismissing its request for a hearing to contest fee review determinations made by the Bureau's Medical Fee Review Section. The pivotal issue raised by Insurer was whether it had liability to pay invoices issued by a billing entity that was not the medical provider. The Bureau held that this is not an issue for a fee review proceeding, and we agree with this conclusion. However, we modify the Bureau's adjudication to vacate the fee review determinations that Insurer challenged.
On December 6, 2013, the Court filed an opinion and order in this case. On February 4, 2014, we granted The Physical Therapy Institute's application for reargument and withdrew the December 6, 2013, opinion and order.
On August 30, 2010, Joseph Kelly (Claimant) injured his neck and left shoulder in a motor vehicle accident while working for Stellar Precision Components, and he received physical therapy to treat these work injuries. Insurer denied The Physical Therapy Institute's invoices for this treatment for the stated reason that it did not actually provide physical therapy to Claimant, explaining as follows:
The Physical Therapy Institute is not the actual healthcare provider who rendered the PT services represented on this bill, and therefore, they are not entitled to payment under the [Workers' Compensation] Act.Reproduced Record at 22a-27a (R.R. ___).
The Physical Therapy Institute filed four separate fee review applications, requesting review of the "amount of payment." R.R. 6a, 152a, 247a, 276a. The first application covered treatment from May 9, 2011, to July 21, 2011, for which it billed $9,664.17. The Bureau's Medical Fee Review Section determined that the amount billed was correct and directed Insurer to pay The Physical Therapy Institute $9,664.17 plus ten percent interest. The second fee review application covered treatment from July 25, 2011, to August 4, 2011, for which The Physical Therapy Institute billed $1,623.80. The Bureau's Medical Fee Review Section determined that the amount billed was correct and directed Insurer to pay The Physical Therapy Institute $1,623.80 plus ten percent interest. The third fee review application covered treatment on August 11, 2011, for which The Physical Therapy Institute billed $405.95. The Medical Fee Review Section determined that the amount billed was correct and directed Insurer to pay The Physical Therapy Institute $405.95 plus ten percent interest. The fourth fee review application covered treatment on August 22, 2011, for which The Physical Therapy Institute billed $405.95. The Medical Fee Review Section determined that the amount billed was correct and directed Insurer to pay The Physical Therapy Institute $405.95 plus ten percent interest.
The Hearing Officer and Insurer reference five fee review applications; however, only four appear in the certified record and are referenced by The Physical Therapy Institute.
Insurer then filed a "Request for Hearing to Contest Fee Review Determination," seeking a de novo hearing on all administrative determinations. R.R. 298a-301a. The matter was assigned to a Hearing Officer in the Bureau. Counsel for each party appeared at the hearing. Counsel for Insurer stated that Insurer denied payment because The Physical Therapy Institute is not a medical provider entitled to payment because it did not actually provide the physical therapy services it was billing. Counsel for The Physical Therapy Institute moved to dismiss Insurer's petitions because the issue it raised was beyond the Bureau's jurisdiction.
Again, the Hearing Officer and Insurer refer to three requests for hearing, but the record contains only two.
The Bureau dismissed Insurer's petitions, concluding that its jurisdiction was limited to disputes over the amount or timeliness of an insurer's payment of medical bills. The Bureau concluded that the issue of whether The Physical Therapy Institute was a "provider" should be litigated before a workers' compensation judge, noting that the parties were, in fact, litigating penalty petitions containing that issue. Insurer then petitioned for this Court's review and requested supersedeas, which was granted by this Court.
On appeal, Insurer presents two issues for our consideration. First, Insurer argues that the Bureau erred by concluding that it lacked jurisdiction over the issue raised in Insurer's fee review petitions. Second, and alternatively, Insurer asserts that the Bureau erred in dismissing Insurer's request for a hearing when it should have dismissed the applications for fee review submitted by The Physical Therapy Institute.
This Court's review of a decision by a Bureau fee review hearing officer is limited to determining whether the necessary findings of fact are supported by substantial evidence, whether constitutional rights were violated, and whether the hearing officer committed an error of law. 2 Pa. C.S. §704; Walsh v. Bureau of Workers' Compensation Fee Review Hearing Office (Traveler's Insurance Co.), 67 A.3d 117, 120 n.5 (Pa. Cmwlth. 2013). --------
This Court addressed these very issues in the companion case of Selective Insurance Company of America v. Bureau of Workers' Compensation Fee Review Hearing Office (The Physical Therapy Institute), ___ A.3d ___ (Pa. Cmwlth., No. 613 C.D. 2013, filed February 4, 2014), which involved the same parties and nearly identical facts. There, we held that the Bureau lacks jurisdiction to determine whether an entity is a "provider" of medical services, or simply a billing agency. This is a question of liability, which is beyond the scope of a fee review and must be decided by a workers' compensation judge. We also held that the Bureau's Medical Fee Review Section lacked jurisdiction to consider The Physical Therapy Institute's fee review petitions in the first instance. These holdings are dispositive in this case.
Accordingly, upon reconsideration, the order of the Bureau's Hearing Office is affirmed as modified to also vacate the Bureau's Medical Fee Review Section's fee review determinations because the issue presented was non-cognizable by the fee review authorities.
/s/_________
MARY HANNAH LEAVITT, Judge
ORDER
AND NOW, this 4th day of February, 2014, the order of the Fee Review Hearing Officer of the Bureau of Workers' Compensation Fee Review Hearing Office dated March 19, 2013, in the above captioned matter is hereby MODIFIED to vacate the fee review determinations by the Bureau of Workers' Compensation Medical Fee Review Section for lack of jurisdiction and AFFIRMED in all other respects.
/s/_________
MARY HANNAH LEAVITT, Judge