Johnson Bros. Corp. v. Thibodaux Regional Medical Center9/28/2001
This is an appeal from a decision of the Office of Workers' Compensation (OWC) finding "outlier" reimbursement due to a health care provider. For the reasons which follow, we affirm the judgment, in part, and remand for additional proceedings.
FACTS AND PROCEDURAL HISTORY
On March 13, 1998, Richard Guise, an employee of Johnson Bros. Corporation (JBC), was injured in a work-related accident. Mr. Guise was treated at Thibodaux Regional Medical Center (Thibodaux Regional) from March 13 to March 17, 1998, where he underwent approximately seven hours of surgery to reduce an open, intra articular, comminuted, fracture of the right tibia and fibula, and a supracondylar-intercondylar fracture of the left distal femur. Because of Mr. Guise's extensive injuries, numerous surgical implants were used to achieve internal fixation during a complicated emergency surgery, which was followed by a four-day hospital stay.
Mr. Guise's hospital charges totaled approximately $43,000.00 at the time of his discharge. After submission of the hospital bill to Gallagher Bassett Services, Inc. (Gallagher), the workers' compensation administrator for JBC, Thibodaux Regional received a payment of $6,448.60. This amount represented inpatient reimbursement for four days of hospitalization at the workers' compensation per diem rate of $1,697.00, applicable to Thibodaux Regional under La. Admin. Code, Title 40, Part I., § 2505.
Subsequently, Oliver J. Bourgeois, III, nurse auditor for Thibodaux Regional, requested Gallagher make payment at the "outlier" rate of eighty-five (85%) percent, under La. Admin. Code, Title 40, Part I., § 2519 (B). Upon receipt of this request, Gallagher retained GENEX Services, Inc. (GENEX), a medical auditing company, to review the request. Following its review, GENEX recommended to Gallagher th at payment be made at the "outlier" rate, entitling Thibodaux Regional to an additional $29,398.03 payment. The recommendation was followed, and the hospital was paid $29,398.03 by Gallagher on or about May 18, 1998. It was stipulated that Mike Swenson, a vice president of JBC, if called to testify, would have testified that the additional payment was made by Gallagher without the knowledge and consent of JBC.
Thereafter, JBC brought this claim against Thibodaux Regional, Gallagher, and GENEX, contending that it is entitled to recover $29,398.03 in medical expenses "which were wrongfully recommended for payment by GENEX Services, ... as an outlier."
After trial of the matter, the OWC judge rendered judgment in favor of Thibodaux Regional, finding "outlier" status and dismissing the claim for reimbursement by JBC. From this judgment, JBC appeals and makes the following assignments of error:
1. The Trial Judge erred in finding that Thibodaux Regional Medical Center met its burden of proof in showing outlier status (non-automatic) under Section 2519B. of Title 40 of the Louisiana Administrative Code providing in pertinent part as follows:
B. Appeal Procedures
Special reimbursement consideration will be given to cases that are atypical in nature due to case acuity causing unusually high charges when compared to the provider's usual case mix. (emphasis added)
2. The Trial Court erred in finding that Thibodaux Regional Medical Center could legally meet its burden of proof without medical testimony to establish case acuity.
3. The Trial Court erred to the extent it relied upon and characterized certain testimony of Oliver Bourgeois, a Nurse Auditor for Thibodaux Regional Medical Center, as expert medical testimony to establish case acuity.
REIMBURSEMENT OF MEDICAL EXPE
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