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Gupta v. Bureau of Workers' Compensation Fee Review Hearing Office (Erie Insurance Co.)

Commonwealth Court of Pennsylvania

November 21, 2013

Sanjay Gupta, M.D., Petitioner
v.
Bureau of Workers' Compensation Fee Review Hearing Office (Erie Insurance Co.), Respondent

Submitted: October 11, 2013

BEFORE: HONORABLE BERNARD L. McGINLEY, Judge HONORABLE P. KEVIN BROBSON, Judge HONORABLE JAMES GARDNER COLINS, Senior Judge

OPINION

JAMES GARDNER COLINS, Senior Judge

Sanjay Gupta, M.D. (Provider) petitions for review of the decision of the Fee Hearing Officer of the Bureau of Workers' Compensation Fee Review Office (Bureau) affirming a determination by the Workers' Compensation Medical Fee Review Section that Provider's Application for Fee Review (Application) was properly denied due to untimeliness under Section 306(f.1)(5) of the Pennsylvania Workers' Compensation Act (Act).[1] 77 P.S. § 531(5). We affirm.

On May 28, 2010, Provider treated a workers' compensation claimant with Therapeutic Magnetic Resonance (TMR). (Medical Fee Review Hearing Decision Finding of Facts (F.F.) ¶3.) On June 25, 2010, Provider billed the claimant's workers' compensation carrier, Erie Insurance Company (Erie), for the procedure in the amount of $3, 298.00. (Id.) On October 20, 2011, over a year after Provider submitted its bill to Erie, Provider filed an Application, which was denied on October 27, 2011 by the Workers' Compensation Medical Fee Review Section because the Application was not filed within the time limits prescribed by Section 306(f.1)(5) of the Act.[2] (F.F. ¶4.) Provider appealed the denial and requested a de novo hearing before the Bureau.

The sole issue before the Bureau was the status of the bill Provider submitted to Erie between June 25, 2010 and October 20, 2011, when Provider submitted the Application. Provider presented the testimony of Beth Sharkey (Sharkey) and Erie presented the deposition testimony of Roxane Lombardi (Lombardi); both parties also submitted documentary evidence. (F.F. ¶¶5-7.) As a result, the Bureau made the following findings of fact:

5. In support of the underlying determination, [Erie] presented the testimony of [Lombardi], the bill review manager for Corvel Corporation, a medical bill repricing company for [Erie]. [Lombardi's] testimony may be stated as follows:
(a)Corvel processes all workers' compensation medical bills for [Erie].
(b)She is familiar with the medical bills in this matter because Corvel processed the Provider's bill of June 25, 2010 for date of service of May 28, 2010 for the amount of $3, 298.00 for APT code 76498. Code 76498 is designated as "unlisted MRI".
(c)Corvel received the Provider's bill, accompanied by medical notes on July 9, 2010, and reviewed same. Based upon a review, Corvel denied the bill as experimental, as per the Medicare guidelines. The denial was communicated to the Provider.
(d) She received the same bill, with the same attached documentation, for the date of service of May 28, 2010, fourteen months later, on September 12, 2011. The bill was denied a second time.
(e) She received the same bill again, with the same attached documentation a third time, on October 27, 2011. Corvel denied the bill again.
(f)On cross examination, Ms. Lombardi was questioned about a conversation that occurred on September 29, 2010 between a billing clerk for the provider and Susan Ketterer, the adjuster on the file at [Erie], regarding the denial by Corvel of payment, and the EOB's[3] dated July 9, 2010.
6. The Provider presented the testimony of [Sharkey], a billing supervisor for East Coast, TMR. East Coast TMR is responsible for the billing and collections for TMR treatments. [Sharkey's] testimony may be stated as follows:
(a) The Provider rendered TMR treatments on two dates of service: May 14, 2010 and May 28, 2010. Payment for the date of service of May 14, 2010 was received; no payment has been ...

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