The board issues fines against an insurance carrier for failing to comply with the Health Care Practice Guidelines where it made only partial payments to a medical provider on four separate claims.

This case involved a motion by a physician group against the insurance carrier seeking to compel full payment of various bills that had been submitted. The decision does not specify the bills, but from other such cases filed by the physician group, it is believed that they were the physician’s reports which, pursuant to the Practice Guidelines, must be paid in the full amount of $30 per report. The bills at issue here had only been partially paid by the carrier. At the legal hearing, the carrier argued that the physician group should be required to file a formal petition with the board before it can seek payment of the bills. The board disagreed and ruled that by making the partial payments, the necessity, reasonableness and causal relatedness of the treatment to the work injury was deemed admitted by the carrier. Therefore, the board reasoned that the physician group could seek full payment of the acknowledged compensable charges by way of a legal motion rather than a petition. On the merits of the case, the oard, in what is believed to be the first decision on this issue, found that the carrier had violated its duty under the Act to either pay the submitted bills within 30 days or contest them through utilization review. There were four separate claims at issue, and the board, as to each of them, ordered the carrier to pay the balance of the bill with interest and also assessed a fine of $1,000 per claim, for a total of $4,000, to be paid by the carrier to the Fund. Finally, claimant’s counsel was awarded a counsel fee of $2,000 for his efforts in getting the bills paid. The lesson of this case is that, while the amounts at issue were not great, failing to comply with the Health Care Practice Guidelines in Delaware can subject employers and carriers to substantial sanctions and fines.

Case Law Alert - 4th Qtr 2011