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Pittsburgh Mercy Health System v. Bureau of Workers' Compensation

August 25, 2009


Per curiam.


AND NOW, this 25th day of August, 2009, it is ordered that the majority opinion filed on May 29, 2009, shall be designated OPINION rather than MEMORANDUM OPINION, and shall be reported.




FILED: May 29, 2009

Pittsburgh Mercy Health System (Provider) petitions for review of the October 2, 2008, order of the Bureau of Workers' Compensation (Bureau), Fee Review Hearing Office, which dismissed as untimely Provider's Application for Fee Review (Application) pursuant to section 306(f.1)(5) of the Workers' Compensation Act (Act).*fn1 We affirm.

On November 21, 2006, Provider billed US Steel Corporation (Employer) in the amount of $734,393.38 for services Provider rendered to Employer's employee Robert Jocz (Claimant). In support of its claim, Provider mailed Employer the documents required by section 306(f.1)(2) of the Act,*fn2 a detailed billing statement with 122 pages of line item entries and Claimant's medical records. Employer informed Provider that its "repricer," MCMC, was auditing Provider's charges. At no time during the audit did Employer or MCMC request any additional documentation from Provider. (Hearing Officer's Findings of Fact, Nos. 1-5.)

On December 27, 2006, Provider received an "Audit Summary" and "Explanation of Review" (EOR) from Employer, in which Employer advised Provider that Employer was denying the claim in part. The EOR explained that the audit revealed a lack of documentation in Claimant's records to support some of the charges and that Employer would pay Provider $499,375.26 for the approved services. The EOR also included the following notice: "If you feel you have been paid incorrectly or untimely, you may file a Fee Review with the Bureau of Workers' Compensation." (R.R. at 296a) (emphasis added). Shortly thereafter, Provider received a check for $499,375.26 from Employer. (Hearing Officer's Findings of Fact, Nos. 6-9.)

After learning of Employer's decision, Marcia Foster, a senior account representative for Provider, collected additional documentation to support the disputed charges and, on January 8, 2007, contacted Employer to see if it would reconsider the denied charges if Provider sent the additional documentation. A "Kathy" advised Foster to send any additional documentation to Valerie Smarra, an employee in Employer's medical department, and Foster did so. Between January 22, 2007, and March 15, 2007, Foster followed up on her reconsideration request by contacting various representatives from Employer and MCMC. On March 15, 2007, a representative from MCMC informed Foster that MCMC was declining to reprocess Provider's claim because the claim already had been reviewed in a line-byline audit. (Hearing Officer's Findings of Fact, Nos. 10-13.)

On March 30, 2007, Provider filed the Application, disputing the amount paid by Employer. (Hearing Officer's Findings of Fact, No. 14.) However, the Bureau denied Provider's Application as untimely. Provider appealed, and a hearing on the timeliness of the Application was held before a hearing officer, at which Provider presented Foster's testimony and documentary evidence.*fn3

Foster testified about the processing of Provider's claim and about her ongoing communications with Employer and MCMC between January 8, 2007, and March 15, 2007. Foster explained that, during these conversations, neither Employer nor MCMC stated that they would not reconsider Provider's claim but, instead, indicated that the request was under review. Foster stated that she only knew Provider's claim finally had been denied on March 15, 2007, and that she filed the Application within thirty days of that date. However, Foster acknowledged that it was Employer's dispute of Provider's claim in the EOR that prompted her to contact Employer on January 8, 2007. (Hearing Officer's Findings of Fact, Nos. 12-15.)

The hearing officer credited Foster's testimony in part but rejected her testimony that Provider first knew its claim was disputed on March 15, 2007. The hearing officer found this testimony was inconsistent with Foster's statement that she became aware of Employer's dispute of the claim in the EOR and with Provider's January 8, 2007, letter to Employer, in which Provider states that it is submitting the additional documents to support the "denied line items." (R.R. at 299a.) Moreover, the hearing officer found that the record did not support Provider's contention that Employer's representations and statements lulled Provider into deferring its fee review application. Accordingly, the Bureau denied Provider's appeal and dismissed the Application as untimely. Provider now petitions this court for review.*fn4

Provider first argues that its Application was timely under the Act because it was submitted within thirty days of March 15, 2007, the date Provider received final notification that Employer was disputing a portion of Provider's claim.*fn5 However, section 306(f.1)(5) of the Act states that an application for fee review must be filed "no more than thirty (30) days following notification of a disputed treatment.." 77 P.S. ยง531(5) (emphasis added). There is nothing in ...

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