Opinion ID: 2544668
Heading Depth: 1
Heading Rank: 5

Heading: What Constitutes the Actual Charge

Text: As Judge Gremillion pointed out in his dissent in Payless Shoesource, [w]hat constitutes the amount the provider charges is ... the critical issue. 10-86 at 9 (Gremillion, J. dissenting). Agilus argues the employer's liability to the injured employee to furnish all necessary medical expenses of the injured employee, is unlawfully relieved when the employer pays an amount less than what the LWCA commands, discussed in the section above. Agilus points to the PPO contract provision, which states the [b]ills shall show Provider's actual charges for the services rendered. Further, Agilus cites La. R.S. 23:1203(B), which provides, The obligation of the employer ... is limited to the reimbursement ... under the reimbursement schedule ... or the actual charge made for the service, whichever is less. (Emphasis added). Thus, for purposes of La. R.S. 23:1203(B), Agilus submits that the actual charge is the standard charge required to be shown on the bill under the contract, not the reimbursement amount listed in the contract. According to Agilus, the employer must pay the standard charge for the services listed on the bill or the LWCA reimbursement schedule amount, whichever is lower. Thus, Agilus argues La. R.S. 23:1203(B) always requires payment of the reimbursement schedule amount if the provider's standard charge is more than the schedule, regardless of any contract dealing with reimbursement. Agilus contends that a health care provider can charge any amount for services, and once reduced to the reimbursement schedule, the amount cannot be further reduced because it would serve to relieve the employer of liability in violation of La. R.S. 23:1033. We disagree. The PPO contract goes on to provide, payor shall be liable for the lesser of provider's billed charges or the amount set forth in Appendix A of this agreement ... According to the contract in this instance, the payor is only responsible to pay the provider the lesser of the listed charge in the bill or the amount set forth in the appendix. As such, the lesser amount would become the charge, i.e. the amount the payor is responsible to pay the provider. Therefore, while the PPO agreement mandates that the actual or standard charge for the services be listed on the bill, it requires only the payment of the lesser of that amount or the amount in the appendix. In this case, the amount listed in the appendix for reimbursement for workers' compensation services is the lesser amount. Thus, it is the charge owed to the provider. Agilus's reading of the contract and its mention of the terms actual charge and reimbursement ignores the fact that the LWCA does not meaningfully distinguished the terms charges and reimbursement. According to the plain language of the statute, the reimbursement schedule is a listing of the maximum charges. See La. R.S. 23:1034.2(C)(1). The LWCA uses the terms fees, charges, and reimbursement throughout referring to the amount to be paid to the provider. See La. R.S. 23:1034.2; La. R.S. 23:1203. We do not read the LWCA as distinguishing between an actual charge and what would be contractually owed to the provider in reimbursement. If a provider contracts to receive a certain amount of reimbursement for a service, we read this to be the actual charge contemplated by La. R.S. 23:1203(B), regardless of the standard charge or where it may be listed. We also note that no part of the employer's liability to furnish adequate medical care to the injured employee is relieved by paying a lower agreed upon fee to the health care provider. At issue here is not the employer's obligation to provide benefits or medical care for the injured employee, but simply the amount of the professional fee that was due and payable to the health care provider for services rendered. Liability to the patient is not affected, as the employer is still liable for the fee, whatever it is determined to be. In no way does paying a lesser amount to the health care provider pursuant to a contract relieve any liability to the injured employee under the LWCA. The employer is simply paying what the provider contractual agreed to charge. The argument has been advanced that these PPO contracts are frequently misapplied and mismanaged and this could lead to health care providers providing less or substandard care to workers' compensation patients. First of all, we note these PPO agreements are just that agreements which can be opted out of or not signed at all. In no way are health care providers forced to enter into these contracts. Further, there has been no evidence advanced, besides conjecture, that indicates that workers' compensation patients are receiving substandard care or that providers are no longer treating workers' compensation patients. Agilus's corporate representative even testified, I think the care, the actual hands-on care delivered by the provider, me, is the same no matter what the insurance coverage is, whether it's worker' comp or health insurance or a network. We find the LWCA specifically contemplates health care providers charging less than the fee schedule for their services to injured workers' compensation patients based on La. R.S. 23:1034.2(E). Further, we find nothing in the LWCA that prohibits a health care provider from contracting to charge less than the reimbursement schedule whether through a PPO or other agreement. We also note that the health care provider in this case voluntarily entered into the PPO agreement with First Health. Agilus was not forced to sign the contract, but did so for the benefit of receiving patient steerage in general, as their corporate representative testified. This was a business decision, and Agilus could have, and did in 2008, opt out of the First Health Network. Agilus claims that by simply listing its standard rate in the bill the LWCA forbids the payment of anything less than the maximum amount listed in the reimbursement schedule, thus relieving them of their obligation under the PPO contract to accept a lesser fee for their care. As discussed above, this is a strained reading of the LWCA and the PPO agreement in question, and we decline to accept it. Because we find that the LWCA does not prohibit PPO discounts for workers' compensation services and that the employer in this case did not under pay for the services rendered, discussion of the issue of penalties and attorneys's fees for underpayment is moot.