Opinion ID: 1111128
Heading Depth: 2
Heading Rank: 1

Heading: In the Matter of Frank Ford.

Text: BOC performed a surgical repair of Frank Ford's torn left rotator cuff. Since Ford's injury resulted from a work-related accident, BOC billed the SIF $2,173.50 for this procedure. This bill included a surgical assist charge of $283.50. BOC billed for its surgical assist at 15% of the underlying procedure. The SIF determined that the underlying surgery exceeded the usual and customary charge by $127.00, and that the surgical assist exceeded the usual and customary charge by $107.20. The SIF issued a preliminary objection and paid BOC the undisputed portion of the bill ($1,939,30). BOC filed a motion for approval of disputed medical charges with the Commission. BOC noted that the service was not frequently documented by BOC and thus sufficient documentation was not available to show that the charge was consistent with the amount charged to non-industrial patients. However, in support of its motion BOC submitted: a copy of the bill to the SIF; a copy of a bill issued to a non-industrial patient; and a copy of a payment received on behalf of an unidentified patient with handwritten Current Procedural Terminology (CPT) codes identifying different procedures. The Commission noted that BOC submitted no evidence as to whether the charges would be allowed by a hospital or professional service corporation. However, finding that the surgical assist was exceptional, unusual, variable, rarely provided, or new, the Commission employed a standard whereby reasonableness is determined on all relevant evidence. As a result, it found that BOC's statement of consistent billing made in its demand for payment letter permit[ted] the inference that the disputed charges were BOC's usual charges. The Commission entered an administrative order finding that the surgical charge did not exceed the usual and customary charge. The Commission also found that although the surgical assist did not exceed BOC's usual charge, the amount did exceed the maximum customary charge allowed ($257.00) based on the Commission's compilation of charges. (A subsequent amendment enlarged the data base from October 1992-March 1993 to July 1992-March 1993.) Payment for the surgical assist was ordered in the amount which did not exceed the maximum customary charge. The SIF filed a motion for reconsideration and a motion to present additional evidence. It renewed its position that BOC did not submit sufficient, competent evidence to support its contention that the charges were usual and customary. It also requested limited discovery of BOC and other providers as to their usual charges for two reasons. First, such information was not available to the SIF. Second, such information was needed for proper consideration of all relevant evidence as to the reasonableness of the disputed charges. The Commission denied the SIF's motion to present additional evidence because it viewed the motion as an attempt to establish the Relative Value Schedule (RVS) as the basis for determining whether the SIF's reimbursement rate was reasonable. The Commission noted that the proper focus was upon the reasonableness of the provider's charge, not the reasonableness of the payor's reimbursement. The Commission granted the motion to reconsider, but after a de novo review upheld the administrative decision and ordered payment. The SIF appealed.