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Royal Insurance v. Department of Labor and Industry3/12/1999
SUBMITTED: November 13, 1998
Royal Insurance (Insurer) petitions this Court for review of an order entered by a hearing officer of the Department of Labor and Industry, Bureau of Workers' Compensation (Bureau), granting payment to The Spine Center (Provider) for the medical treatment it provided to Dorothy Williams (Employee). In its petition for review, Insurer requests that the Bureau's order be reversed and dismissed, that a stay be granted pending final determination by the Workers' Compensation Judge (WCJ) or that a remand before the hearing officer be ordered to permit Insurer to present new evidence. Insurer questions whether a hearing officer presiding over a medical fee review proceeding has the authority to order payment of bills for medical treatment which has not yet been determined to be related to a compensable work injury.
On March 10, 1997, Provider filed an application for medical fee review pursuant to Section 306(f.1) of the Workers' Compensation Act (Act) seeking reimbursement from Insurer for the cost of medical treatment provided to Employee on December 20 and 27, 1996. On July 15, 1997, the Bureau issued an administrative decision on the fee review, granting payment to Provider. Insurer filed a request for a hearing de novo seeking review of the administrative decision by the Bureau's fee review hearing office. At the hearing, Insurer argued that the WCJ had not yet determined whether the bills were related to the compensable work injury and, therefore, that the fee determination should be held in abeyance pending the WCJ's decision. Provider countered by asserting that Insurer had not presented evidence to show that the issue of causal relatedness was preserved before the WCJ and, as a result, payment of the medical bills should be ordered.
The hearing officer found that Insurer failed to prove that it had challenged or was in the process of challenging the causal relationship between the work-related injury and Provider's medical expenses. The hearing officer also determined that there was no evidence to show that Insurer had properly served Provider with notice that it was seeking a utilization review. Moreover, the officer found that the utilization report was not submitted into evidence. As a result, Insurer failed to establish that the WCJ's pending decision would affect Provider's entitlement to reimbursement for the medical expenses. In light of these findings, the hearing officer ordered payment of the bills to Provider with applicable interest computed on the sum.
A review by the Court of a hearing officer's order involving a medical fee review is limited to determining whether constitutional rights were violated, whether an error of law was committed or whether the necessary findings of fact were supported by substantial evidence. Catholic Health Initiatives v. Health Family Chiropractic, 720 A.2d 509 (Pa. Cmwlth. 1998). Under administrative agency law, a fact finder is required to base factual findings on competent evidence. Department of Transportation, Bureau of Traffic Safety v. Uebelacker, 511 A.2d 929 (Pa. Cmwlth. 1986).
Insurer cites the medical cost containment regulations, 34 Pa. Code Chapter 127, to support its contention that the hearing officer acted outside the scope of her authority. Section 127.251, 34 Pa. Code ยง127.251, states in relevant part: "A provider who has submitted the required bills and reports to an insurer and who disputes the amount or timeliness of the payment made by the insurer, shall have standing to seek review of the fee dispute by the Bureau." Insurer argues that the hearing officer cannot make a determination about timeliness or amount where a dispute about the relatedness of the tre
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