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Roman Catholic Diocese of Allentown v. Bureau of Workers' Compensation

October 28, 2011


The opinion of the court was delivered by: Robert Simpson, Judge

Argued: September 13, 2011



In this appeal involving the trauma center exemption from the medical fee caps in the cost containment provisions of the Workers' Compensation Act*fn1

(Act), the Roman Catholic Diocese of Allentown (Employer), self-insured, petitions for review of an order of Hearing Officer Richard C. Lengler (Hearing Officer), of the Bureau of Workers' Compensation, Fee Review Hearing Office (Bureau). Hearing Officer affirmed the Bureau's decision directing Employer to pay the Lehigh Valley Health Network (Provider) 100 percent of its billed charges for acute care provided to Father James Mulligan (Claimant) for immediately life-threatening or urgent injuries at Provider's Lehigh Valley Hospital-Cedar Crest (Hospital), which is an accredited level I trauma center.

Employer contends Hearing Officer: erred in failing to dismiss Provider's fee review application as untimely; erred in failing to reverse the Bureau's decision because competent and credible evidence produced at the fee review hearing showed Claimant's injuries did not constitute "immediately life-threatening" or "urgent" injuries for purposes of the trauma center exemption as defined by 34 Pa. Code §127.128;*fn2 and violated Employer's constitutional right to due process by precluding Employer from presenting expert medical testimony by telephone at the fee review hearing. For the reasons that follow, we affirm.

I. Background

A. EMS Transport

In early January 2009, Claimant, a 72-year old male, sustained a work-related injury when he fell on an icy sidewalk and injured his back. Claimant remained outside for about five minutes before someone found him. An EMS ambulance unit responded within 10 minutes of dispatch. At the scene, Claimant complained of severe back pain and also stated he hit his head. Claimant did not lose consciousness. The EMS unit immobilized Claimant. He refused a cervical collar and gave a history of a fused cervical spine. EMS contacted Hospital's medical command center and transported Claimant to Hospital.*fn3 At all relevant times, Hospital was an accredited level I trauma center.

B. Hospitalization

Shortly after Claimant's admission by nursing staff as an acuity level III patient, Provider's physicians determined Claimant's injuries included two unstable spinal fractures. Therefore, they ultimately admitted him as a trauma patient and placed him in Hospital's Trauma-Neuro Intensive Care Unit (TraumaNeuro ICU).*fn4 Patients who do not have immediately life-threatening or urgent injuries are not typically placed in the Trauma-Neuro ICU. Approximately two days later, Claimant underwent spinal surgery. He remained a trauma patient until his discharge on January 23, 2009.

C. Provider's Bill

Employer accepted Claimant's injuries as work-related. In May 2009, Provider submitted a detailed bill on the proper forms to Employer with copies of medical records relevant to treatment. See Reproduced Record (R.R.) at 846a-74a. Provider's bill totaled $406,338.79. Id. at 848a, 874a.

D. Employer's EOB/Payment

In November 2009, Employer issued an explanation of benefits (EOB) that approved payment to Provider under workers' compensation fee schedule for inpatient hospital services in the amount of $142,196.00. See id. at 875a-77a. Employer issued a check for this amount. Id. at 878a. In short, Employer reduced Provider's charges by $264,142.79. Id. at 877a.

E. Fee Review Application/Bureau Determination

Three days after receiving Employer's EOB, Provider filed a fee review application challenging the amount of payment. Id. at 1a-2a. The Bureau determined Provider was entitled to the full amount of its bill and directed Employer to pay the outstanding $264,142.79 plus interest. Id. at 3a-9a. Employer filed an appeal and requested a fee review hearing. Id. at 10a-19a.

F. Hearing

At hearing, Employer's fee auditor/reviewer and assets recovery specialist, Sean McLaughlin (Insurance Auditor) testified as an expert. Auditor testified he is the president and chief executive officer of Liberty Assets Recovery, a company that audits and reviews medical bills for insurance carriers in workers' compensation cases. He is familiar with the Act's medical cost containment provisions and the ACS field triage guidelines. Insurance Auditor reviewed Claimant's medical documentation and opined that Claimant's injuries were not immediately life-threatening or urgent for purposes of trauma transport and hospitalization.

Employer also sought to present medical testimony by telephone from Dr. Steven Feinstein (Employer's Physician). However, Hearing Officer sustained Provider's objection and precluded Employer's Physician's testimony on the basis that Employer did not identify Physician as an expert or a telephone witness in its pre-hearing filing as required by the Bureau's pre-hearing instructions.

Dr. Michael Pasquale (Provider's Physician), testified for Provider. He opined that spinal fractures, particularly if they are unstable, are considered immediately life-threatening or urgent injuries. Spinal cord injuries may result in paralysis, especially in elderly patients. Therefore, Provider's Physician opined any patients with spinal injuries should be evaluated at a trauma center.

Provider's Physician further testified the ACS guidelines concerning inter-hospital transfers also list spinal fractures as life-threatening injuries requiring transfer to a level I or level II trauma center. See ACS Guidelines for Inter-hospital Transfer; R.R. at 960a-62a. Provider's Physician testified the standards for inter-hospital transfers are the same as those for initial transfers of trauma patients.

Provider's Physician also testified he reviewed Claimant's medical records. Hospital's trauma service evaluated Claimant in the emergency room and diagnosed two unstable spinal fractures. Hospital then admitted him as a trauma patient in the Trauma-Neuro ICU. Claimant remained a trauma patient throughout his stay at Hospital.

Provider also presented testimony from its director of patient financial services, Jeff Hinkle (Financial Services Director), who testified Provider maintained its certification as a level I trauma center for the past 20 years. Therefore, Hospital was accredited as a ...

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