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SAUL Z. KOPEIKA v. MEDICAL SERVICES ASSOCIATION PENNSYLVANIA T/D/B/A PENNSYLVANIA BLUE SHIELD (11/15/85)

filed: November 15, 1985.

SAUL Z. KOPEIKA, D.D.S., APPELLANT,
v.
MEDICAL SERVICES ASSOCIATION OF PENNSYLVANIA T/D/B/A PENNSYLVANIA BLUE SHIELD, A CORPORATION



Appeal from the Order Entered June 4, 1984 in the Court of Common Pleas of Delaware County, Civil Division, at No. 81-03850.

COUNSEL

W. Russell Carmichael, Media, for appellant.

Edward R. Paul, Media, for appellee.

Wieand, Watkins and Geisz,*fn* JJ.

Author: Watkins

[ 347 Pa. Super. Page 502]

This is an appeal from an Order entered June 4, 1984 in the Court of Common Pleas of Delaware County denying

[ 347 Pa. Super. Page 503]

    appellant's Motion for New Trial and Judgment, n.o.v., and entering judgment for the appellees.

Appellant is a dentist licensed to practice dentistry in Pennsylvania. Appellee is a non-profit professional health service corporation organized pursuant to Blue Shield Regulatory Act (40 P.S. ยง 6301, et seq.) Appellant is a voluntary participating dentist in the Blue Shield Dental Program whereby he is compensated pursuant to a schedule for necessary services performed upon a Blue Shield subscriber.

On January 30, 1980, appellant was advised by Blue Shield that a review of his dental service reports (claim forms) indicated that, in the opinion of the dental director of Blue Shield, Richard J. Wroblewski, D.D.S., some of the periapical X-Rays taken by the appellant appeared to have not been necessary. Effective February 4, 1980, appellant would be required to show specific need for the periapical X-Rays if he wished Blue Shield to compensate him for the same. On February 11, 1980, appellant wrote to the State Dental Council and Examining Board, stating that Blue Shield prescribed and made determinations on the adequacy of patient treatment and possibly maintained fraudulent records. Appellant also requested information from the Board on the terms "not necessary", "high utilization" and "excessive".

Dr. Wroblewski wrote to the Board in response on March 19, 1980. The letter advised the Board of the background of appellant's request and attached the claim forms of six patients alleged to support Dr. Wroblewski's opinion.

The Board assigned one of its members, Dr. Leon Penzur, to review the six claim forms. Dr. Penzur reported to the Board that his review indicated excessive use of radiographs (X-Rays) in violation of American Dental Association and Pennsylvania Dental Association guidelines. The Board then requested appellant to appear for an informal hearing with the X-Rays and dental records pertaining to the six ...


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