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Successfully Defended University in Case Involving Three Suspicious Compound Cream Prescriptions.

We successfully defended a Philadelphia-based university in an action by a local medical provider for submissions of compound cream medication. The provider submitted the medication to the carrier via three medical specialists from the same medical group. The first doctor submitted an expensive bill for the compound cream to the carrier for payment. A second doctor from the same office submitted another expensive bill for the same compound cream, allegedly based on an exam that took place on the same day as the first doctor’s exam. Then a physician’s assistant submitted an expensive bill for the same compound medication, allegedly arising out of an exam she had with the claimant on the same day as the first two doctors. The carrier refused payment of the bills and filed a Utilization Review Request against all three providers. The UR requests came back in the carrier’s favor, and the providers’ attorney filed a review petition to challenge the UR determinations. We defended the review by establishing that the providers illegally billed the carrier for exams that allegedly took place on the same day, resulting in the same medication being prescribed and submitted for payment three separate times by three separate practitioners. The judge found the medical providers not to be credible and upheld the UR determination in its entirety.

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