Only the fee review arena has the authority to decide the issues of medical billing amounts, timeliness and who qualifies as a medical provider under the Act.

In this case, following a serious burn injury sustained by the claimant after falling in a puddle of hot water at work, the claimant filed a penalty petition, alleging that the employer failed to pay her physicians and hospitals over $410,000 for acute care she received. The employer denied these allegations. 

Prior to filing the penalty petition, the medical providers filed applications for Fee Review as they were not satisfied with the amounts issued by the employer. Following an administrative decision, the employer’s insurer requested a de novo hearing before a Fee Review Hearing Officer. The Hearing Officer circulated a decision, finding the Fee Review applications filed by Professional Receivables Network (PRN) involved an entity that was not a medical provider under § 127.23 of the Medical Cost Containment Regulations. According to the Hearing Officer, a determination as to whether PRN was a provider exceeded his jurisdiction and the issue of the entity’s standing to file applications must be decided by a Worker’s Compensation Judge. 

In the decision on the penalty petition, the judge determined he lacked jurisdiction to decide the issue of billing amounts as that was in the province of the Hearing Officer. Thus, according to the judge, there was no basis upon which to impose a penalty. The judge noted that because of Armour Pharmacy v. Bureau of Workers’ Comp. Fee Rev. Hearing Off. (Wegman’s Food Mkts, Inc.), 206 A.3d 660 (Pa. Cmwlth. 2019), the Hearing Officer now has jurisdiction to decide the issue of who is a provider within the scope of the Fee Review proceeding. The judge directed the claimant and the health care provider to seek relief from a Hearing Officer. The claimant appealed to the Appeal Board, which affirmed.

At the Commonwealth Court level, the claimant argued that under Armour Pharmacy, the issue of whether an entity is a provider can be resolved by either a Workers’ Compensation Judge or a Hearing Officer. The claimant further argued that, because a penalty is a percentage of the bills, the judge must calculate the amount before determining the amount of the penalty and that these are issues also to be decided by the judge. In dismissing the claimant’s appeal, the court noted that an appeal of the Hearing Officer’s decision regarding lack of jurisdiction was not filed by the providers. At the time of the Hearing Officer’s decision, Armour Pharmacy had not yet been decided. Armour Pharmacy said that only the Fee Review arena had the authority to decide billing amounts, timeliness and the matter of who qualifies as a provider under the Act. The only determination the judge could have made was whether PRN was a provider under the Act. The Commonwealth Court, therefore, affirmed the decisions of the Workers Compensation Judge and the Appeal Board. 

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