Case Law Alerts
Challenging the Medical Fee Review Section’s fee determination that medical service not rendered by “provider” within meaning of the Act.
The employer had denied payment of compound pain creams that were dispensed to the claimant by Armour Pharmacy. The pharmacy then filed three fee reviews. The Bureau’s Medical Fee Review Section ordered payment, and the employer filed requests for de novo hearings. The Fee Review Hearing Office vacated these three determinations, directing the employer to reimburse the pharmacy for medications it had dispensed to the claimant.
Later, the employer filed a motion to dismiss its own challenges/appeals to the fee review determinations, arguing that, because the pharmacy was not a provider within the meaning of the Act, the hearing office lacked jurisdiction. The pharmacy opposed the motion, maintaining that the employer had waived this argument by not raising the issue at the time it denied the pharmacy’s bills. The employer’s motion was granted. In the pharmacy’s appeal, it argued that it was denied due process since it was left without a forum to challenge the employer’s refusal to reimburse it for medications it dispensed to the claimant for his work injury.
The Commonwealth Court held, where an employer challenges a fee determination of the Medical Fee Review Section on the basis that the medical service was not rendered by a “provider” within the meaning of the Act, that threshold question must be decided by the hearing office. Jurisdiction, as a quasi-judicial matter, is not to be decided by the Medical Fee Review Section, whose sole responsibility is administrative and whose inquiry is limited to the timeliness of payment and the correct amount of reimbursement owed to the provider. The court reversed the hearing office’s adjudication and remanded the matter for determination of whether the pharmacy was a provider, within the meaning of the Act.
Case Law Alerts, 3rd Quarter, July 2019
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