Employer must pay 100% of charges billed for acute care provided from accredited Level I Trauma center to a claimant for immediately life threatening or urgent injuries.

An elderly claimant sustained work-related injuries after he fell on an icy sidewalk and remained outside for five minutes before he was found. An ambulance responded, and the claimant was immobilized. He was transported to the hospital by the EMS unit, where it was determined that he sustained two unstable spinal fractures. The claimant was admitted as a trauma patient and placed in the intensive care unit. Two days later, he underwent spinal surgery and remained a trauma patient until his discharge.

The employer accepted the claimant's injuries. The provider billed the employer $406,338.79 for their services. The employer issued an explanation of benefits (EOB) approving payment for $142,196. Three days after receipt of the EOB, the provider filed a fee review application. The Bureau determined that the provider was entitled to the full amount of the bill. The employer appealed and requested a fee review hearing. The hearing officer determined that the claimant's condition and assessment qualified for Level 1 Trauma transport and hospital admission/treatment and concluded that the employer must pay the provider 100% of its charges in that the trauma center exemption from the Act's medical fee caps applied.

On appeal to the Commonwealth Court, the employer primarily argued that the trauma center exemption did not apply. According to the employer, the claimant did not meet any of the criteria in steps 1 -3 of the ACS Triage Guidelines and the medical evidence produced at the hearing established only that the claimant's condition was potentially and not immediately life threatening or urgent.

The Commonwealth Court rejected the employer's arguments and affirmed the decision of the hearing officer. The court pointed out that the decision by the EMS personnel that an injury is immediately life threatening or urgent, absent a violation of ASC Guidelines, is presumptive of the reasonableness and necessity for transport to a trauma center.

Case Law Alert - 1st Qtr 2012