Fee review application cannot be barred by collateral estoppel where the hearing officer fails to conduct a hearing or address whether the insurer strictly complied with § 127.207 of the medical cost containment regulations.

In this case, the provider performed Therapeutic Magnetic Resonance (TMR) treatments on the claimant and billed them to the carrier at $3,298 per treatment. The carrier downcoded the procedure and paid the provider $26.24 per treatment. The provider then filed fee review applications with the Bureau disputing the amount that was paid. The Medical Fee Review Section of the Bureau held that proper reimbursement was made to the provider, who appealed by filing applications to a hearing officer. The hearing officer, without holding a hearing, dismissed the fee review applications, holding that the issue was identical to an issue that had already been fully adjudicated. The provider appealed to the Commonwealth Court.

The Commonwealth Court reversed the hearing officer's decision. The court held that the hearing officer improperly concluded that the provider's fee review application was barred by collateral estoppel because the hearing officer did not conduct a hearing or address whether the insurance carrier strictly complied with §127.207 of the regulations.

Case Law Alerts, 3rd Quarter 2013