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

Heading: In the Matter of David Wilson.

Text: BOC performed an arthroscopic decompression of the subacromial space with a partial ostectomy on David Wilson's shoulder and a fasciotomy with a partial ostectomy on his elbow. Since Wilson's injury resulted from a work-related accident, BOC billed the SIF $3,121.38. Included in this bill was a charge for a surgical assist on the shoulder surgery ($301.88) and a similar charge for the elbow surgery ($107.00). These charges were based on 15% of the underlying procedure. The SIF determined that the amounts charged for the surgical assists exceeded the usual and customary charge by $100.63 for the shoulder surgery and $37.00 for the elbow surgery. BOC received an explanation of benefits and was paid the undisputed portion of its bill ($2,983.75). BOC filed a motion for approval of disputed medical charges with the Commission. In support of its motion, BOC submitted: its bill with the disputed charge; a copy of an explanation of benefits from an unnamed payor containing handwritten CPT codes; and a copy of an explanation of benefits from Idaho Power with a handwritten CPT entry. The Commission noted that BOC submitted no evidence that a hospital or professional service corporation would allow the charges. However, the Commission found that BOC's demand for payment letter permitted the inference that the disputed charges were its usual charges. As a result, the documentation provided and the Commission's compilation of charges from October 1992 to March 1993 supported the conclusion that the disputed charges were reasonable. (Again, a subsequent amendment enlarged the range to July 1992March 1993.) The SIF filed a motion to reconsider and a motion to present additional evidence. The Commission denied both motions. Since the Commission had not adopted RVS or a standard which focused on the reasonableness of the reimbursement rate, it felt evidence of such standards was irrelevant. The Commission focused on the reasonableness of BOC's charges and found they were supported by sufficient evidence. The SIF appealed. These two cases were consolidated for the purpose of appeal. After the SIF filed its notice of appeal, BOC sought and received a waiver from further participation in these proceedings.