Testimony given by the insurer’s repricing manager regarding the use of a database to determine the usual and customary charges for trauma care was not substantial evidence to support use of the database.

The Commonwealth Court concluded that the testimony of the insurer’s witness, the repricing manager, had no application to the payment for charges exempt from the fee caps. The court pointed out that, although they concluded in a recent decision that a comparison to other medical providers’ charges could be made to reprice the cost of trauma care, they, nevertheless, questioned the use of a database for that purpose. See Geisinger Health System and Geisinger Clinic v. Bureau of Workers’ Compensation Fee Review Hearing Office, ___ A.3^rd ___ (Pa. Cmwlth. 1627 C.D. 2015, filed April 21, 2016, 2016 WL 1592957). The court held that the Hearing Officer erred in concluding that the insurer properly reimbursed the provider. However, the court agreed with the Hearing Officer that the provider need not be reimbursed at 100% of actual charges. The charges can be compared to those by other accredited trauma centers in the same geographic region in order to arrive at the “usual and customary charge” for trauma care. Reimbursement is then made at 100% of such charges. Therefore, the court reversed the Hearing Officer’s decision and remanded the case for a determination of the “usual and customary charge.”

_{Case Law Alerts, 4^th Quarter, October 2016. Case Law Alerts is prepared by Marshall Dennehey Warner Coleman & Goggin to provide information on recent developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. Copyright © 2016 Marshall Dennehey Warner Coleman & Goggin, all rights reserved. This article may not be reprinted without the express written permission of our firm.}