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The Act does not require a workers' compensation carrier to pay the full amount of a medical provider's bill if it does not downcode the bill within 30 days of the date it was submitted.

October 1, 2011
Dr. Jeffrey Yablon & Dr. Vincent Ferrara v. Bureau of Workers' Compensation Fee Review Hearing Office; 2042 C.D. 2010; filed April 21, 2011; opinion by Judge Pellegrini

In this case, Jeffrey Yablon, M.D. and Vincent Ferrara, M.D. appealed a determination made by a fee review hearing officer that the workers' compensation insurer did not lose the right to "downcode" charges because more than 30 days had passed after the bill had been submitted. The bills submitted for payment by the providers were for VAX-D treatment. The bills used an unlisted code, but the insurer downcoded the bills to that of mechanical traction, which resulted in a smaller fee paid to Drs. Yablon and Ferrara. The insurer did not notify the physicians of the intent to downcode until after 30 days from submission of the bills had passed. At the fee review level, the providers argued that once the 30 days for payment had passed, the insurer was barred from downcoding and was required to pay the full amount of the bill. The hearing officer disagreed, finding that the violation of the 30-day limitation would result in interest payments to the providers, not a bar to the ability to downcode. The Commonwealth Court agreed with the hearing officer and dismissed the appeal filed by Drs. Yablon and Ferrara. According to the court, the penalty provided for in the regulations for an insurer's failure to institute the downcoding procedure within 30 days is the same as non-payment of the bill – interest on the unpaid balance at 10 percent.

Case Law Alert - 4th Qtr 2011

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Francis X. Wickersham
Shareholder
(610) 354-8263
fxwickersham@mdwcg.com
G. Jay Habas
Managing Attorney, Erie, PA Office
(814) 480-7802
gjhabas@mdwcg.com

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