Employer is entitled to have medical bills submitted in a “clean claim” format, which includes having the provider submit the bills on the proper forms.

Claimant’s counsel submitted to counsel for the employer medical bills for the claimant’s work-related surgery. The Board, as its starting point, stated that the applicable principle was that a general agreement to pay for surgery is not an agreement to pay for specific medical bills. They further noted that under the provisions of the Act, an obligation to pay bills is not triggered until a proper “clean claim” is submitted to the employer. The Board then addressed the question of what data is required in order to constitute a “clean claim.” In authorizing the development of the Healthcare Payment System and the regulations adopted along with it, the Act clarifies what is needed for a proper “clean claim.” In analyzing that issue, the Board concluded that the employer is within its rights to demand that the charges be submitted on a HCFA form. The Board noted that under the current fee schedule Guidelines, the CMS-1500 form is the same as the previous HCFA form 1500. The Board concluded that the employer was acting properly by delaying payment until the providers had submitted the medical charges on the required forms. The evidence showed that once the employer had received the proper forms from the providers, those charges were paid. There were some remaining charges that were being disputed on the basis of billing codes and bundling issues. The Board suggested that the parties attempt to resolve that issue, but that, if they could not, the appropriate DACD petition could be filed. In the meantime, the Board denied the claimant’s motion for payment of the medicals.

Case Law Alerts, 1st Quarter, January 2015