Court Opinion

ID: 4963794
Source: CourtListenerOpinion
Date Created: 2021-09-24 15:31:26.532684+00
Date Added: 2024-06-11T08:15:58.698367
License: Public Domain

CLIFFORD, J.,
with whom SAUFLEY, C.J. and ALEXANDER, J., join, dissenting.
[¶26] In enacting the 1992 reform of the Workers’ Compensation Act, the Legislature expressed its intention to limit overall costs to the workers’ compensation *404system, including the cost of health care. Contrary to that intent, the Court, relying on 39-A M.R.S. § 209(2) (2007), concludes that employers and insurers may not challenge amounts charged by medical facilities for outpatient surgical services provided to employees as long as the amount charged equals the published rate that the facility lists as its initial charge to all pay-ors. In so doing, the Court ignores provisions of the Act and Board rules that limit what health care facilities are permitted to charge for services to injured employees, and that expressly permit — and even require — insurers and employers to challenge excessive or unreasonable charges. The Court’s decision allows health care facilities to dictate what employers must pay, even if those payments are well in excess of what other private third-party payors pay for the same services. Accordingly, I respectfully dissent.
I. DISCUSSION
[¶ 27] Section 209(2)12 provides that a health care facility “must be paid either its usual and customary charge for any health care services or the maximum charge established” by rules adopted by the Board pursuant to section 209(1). The Board, however, has not promulgated rules establishing maximum charges applicable to facilities for outpatient surgical procedures. In the absence of rules promulgated by the Board, we are asked to decide whether workers’ compensation insurers and employers are entitled to challenge the amount billed to them by outpatient surgical facilities on the ground that the charges are not the facility’s “usual and customary charges” or that the charges are unreasonable. I would conclude that the employers and insurers are entitled to challenge those charges.
[¶28] The hearing officer determined that (1) “usual and customary charge” means the rate, published pursuant to 22 M.R.S. § 1718 (2007),13 that the provider charges as an initial matter to all payors, and (2) employers and insurers are prohib*405ited from challenging that rate with contrary evidence developed either through discovery of what private third-party pay-ors are asked to pay or by expert testimony regarding the market rate. The Court affirms that ruling.
[¶ 29] I agree with the Court that pursuant to section 209(2), in the absence of a Board-promulgated fee schedule, the employer is obligated to pay the “usual and customary charge.” I disagree, however, as to the meaning of that term, and that section 209(2) prohibits employers from presenting evidence of what other entities are being charged for the same service. In construing section 209(2), I would give effect to the intent of the Legislature.
In determining the legislative intent, we look first to the plain meaning of the statutory language, and we construe that language to avoid absurd, illogical or inconsistent results. In addition to examining the plain language, we also consider the whole statutory scheme of which the section at issue forms a part so that a harmonious result, presumably the intent of the Legislature, may be achieved. If the statutory language is ambiguous, we then look beyond the plain meaning and examine other indicia of legislative intent, including its legislative history.
Jordan v. Sears, Roebuck & Co., 651 A.2d 358, 360 (Me.1994) (citations and quotation marks omitted).
A. Plain Meaning
[¶ 30] At issue is the meaning of the words “usual and customary charge” in section 209(2). The Court concludes that the word “charge” means the amount that the facility bills to all patients, which is the amount on the price list for the medical service that is maintained by the provider pursuant to 22 M.R.S. § 1718. Since the facilities “charge” the same rate to all customers, the Court concludes that the “statute is satisfied,” i.e., that the published charge is the usual and customary charge, even though the facility accepts less as payment in full for the same service from some private third-party payors. I disagree for two reasons.
[¶'31] First, nowhere in the Workers’ Compensation Act is “usual and customary charge” defined with reference to Title 22.
[¶ 32] Second, while the word “charge” has many meanings, in this context it plainly means “the price demanded for a thing or service” or “to fix or ask (a sum) as a fee or payment.” WebsteR’s Third New International Dictionary 377 (3d ed.2002). Just because a provider writes an amount on a bill does not mean that amount is the “charge” if the provider is not demanding that amount in payment for the service, and in fact has separately agreed to accept a lower price. Moreover, if only a small minority of patients are expected to pay the amount on the bill, *406certainly it cannot be fairly characterized as the usual and customary charge.
B. Whole Statutory Scheme
[¶ 33] An examination of the whole statutory scheme of which section 209(2) forms a part indicates that the Legislature intended that amounts charged to private third-party payors be considered when determining the limitations on what may be charged to workers’ compensation insurers and employers.
[¶ 34] Section 209(1) requires that the Board adopt rules that establish “standards, schedules, or scales of maximum charges” for health care services for the express purpose of ensuring “appropriate limitations on the cost of health care services” to the Workers’ Compensation System. In so doing, the Legislature mandated that the Board consider “maximum charges paid by private 3rd-party payors for similar services provided by health care providers in the State.” Id. This provision indicates that the Legislature considered the amounts paid by private third-party payors as relevant in determining what the maximum charge for medical services should be.
[¶ 35] The Court concludes that section 209(1) indicates that amounts paid by private third-party payors are relevant only in the rulemaking process and are not relevant to determining whether a charge is excessive on a case-by-case basis. The rulemaking process has not occurred, however, and to require employers and workers’ compensation insurers to pay the amount unilaterally determined by the facilities without that amount being compared to and limited by what other private insurers are paying contravenes the intent of the Legislature.
[¶ 36] Section 209(3), expressly subtitled “[(limitations on reimbursement,” also demonstrates that amounts paid for the same service by private third-party payors are relevant to an inquiry regarding “usual and customary charge.” It provides that
[i]n order to qualify for reimbursement for health care services provided to employees under this Title, health care providers providing individual health care services and courses of treatment may not charge more for the services or courses of treatment for employees than is charged to private Srd-party payors for similar services or courses of treatment.
(Emphasis added.) This provision indicates that the Legislature intended that (1) limitations be placed on the amount that providers can be reimbursed for health care services provided to injured employees, and (2) those limitations are defined by the amounts that private third-party payors pay for the same services. Limiting the meaning of “charge” in section 209(3) to the amount on a bill the provider sends to all payors, instead of the amount that the provider has agreed to accept as payment in full from some of those payors, makes little sense if that bill does not reflect the amount that the provider is in fact demanding in payment. The Court’s definition of the word “charge” renders the intended limitations placed on what providers can be reimbursed meaningless.
[¶ 37] When read together, subsections 209(1), (2), and (3), demonstrate that the amount demanded as payment from private third-party payors for the same service is highly relevant to an inquiry regarding what the usual and customary charge is for that service. Other statutes and Board rules support the conclusion that employers should be entitled to challenge the facility’s asserted charge.
[¶ 38] Title 39-A M.R.S. § 206(7) (2007) requires employers to make prompt payment for medical services provided to *407the employee, only “if the costs are necessary and adequate and the charges reasonable.” (Emphasis added.) Requiring employers to accept the published charge denies the employer/insurer the right to challenge the reasonableness of the charge for the medical services, and allows health care providers to unilaterally determine what the workers’ compensation system is required to pay for those medical services.
[¶ 39] Me. W.C.B. Rule, ch. 5, § 9(3) states that “the insurer shall undertake reasonable investigations to ascertain whether a service is subject to the maximum allowable payment.” Moreover, if employers/insurers dispute the amounts charged, Board rules allow them to adjust the amount of the bill and notify the health care provider that the requested fee has been adjusted and provide an explanation for the adjustment, subject to a petition to fix. Id.
[¶ 40] Not only can the insurer adjust the payment, the insurer/employer may under certain circumstances be entitled to challenge the charges pursuant to a medical utilization review process. 39-AM.R.S. § 210(2007). Section 210 allows an insurance carrier, self-insured employer or group self-insurer to evaluate the appropriateness of health care services provided to an injured employee, based on medically accepted standards. 39-A M.R.S. § 210(2).14 If it is determined that “a health facility or health care provider has made any excessive charges or required unjustified treatment, hospitalization or visits, the health facility or health care provider may not receive payment ... from the insurance carrier, self-insurer or group self-insurer for the excessive fees or unjustified treatment_” 39-A M.R.S. § 210(7). The Board has promulgated rules governing the utilization review process. Me. W.C.B. Rule, ch. 7. While the utilization review process was not used in this case, it indicates that the Legislature intended that medical providers be subject to certain limitations, and that they are not free to impose charges on employers and insurers that are excessive or receive payment for unnecessary medical procedures.
C. Legislative History
[¶ 41] Section 209 was passed as part of the 1992 reform of the Workers Compensation Act. That reform effort was intended to reduce workers’ compensation costs to employers and attract employers to the state, as well as cut costs to the system as a whole. 7 Legis. Rec. S-40-43 (3rd Spec.Sess.1992); 7 Legis. Rec. H-50-52, 76-81, 91-100 (3rd Spec.Sess.1992); Blue Ribbon Commission to Examine Alternatives to the Workers’ Compensation System and to Make Recommendations Concerning Replacement of the Present System, Report of the Blue Ribbon Commission (Aug. 31, 1992); P.L.1991, ch. 885, Emergency Preamble (adopting recommendations of the Blue Ribbon Commission); see also Temm v. S.D. Warren Co., 2005 ME 118, ¶ 13, 887 A.2d 39, 43 (stating overall purpose of the workers’ compensation reform of 1992 was to reduce costs on the workers’ compensation system).
*408[¶ 42] For the Court to allow the health care providers to charge more for services rendered to employees for workplace injuries for which employers are responsible under the workers’ compensation system than they charge to other payors, and to unilaterally determine what the workers’ compensation system is required to pay for medical services, is contrary to the overall purpose of the workers’ compensation reform of 1992, to specific provisions of sections 209 and 206, and to the rules promulgated by the Board that allow insurers and employers to challenge excessive charges.
[¶ 43] Accordingly, I would vacate the decision of the hearing officer granting CMO’s petitions for payment of medical and related services in these cases, and I would remand to allow discovery regarding what constitutes the usual and customary charge for the medical services in issue, including amounts paid by private third-party payors for the same services, and for a hearing at which the issue of whether the amounts charged constitute the “usual and customary charge” or a reasonable charge for the services provided.

. Title 39-A M.R.S. § 209 (2007) provides in relevant part:
1. Standard, schedules or scales. In order to ensure appropriate limitations on the cost of health care services, the board shall adopt rules that establish:
A. Standards, schedules or scales of maximum charges for individual services, procedures or courses of treatment. In establishing these standards, schedules or scales, the board shall consider maximum charges paid by private 3rd-party payors for similar services provided by health care providers in the State and shall consult with organizations representing health care providers and other appropriate groups.
2. Payment for services. A health facility or health care provider must be paid either its usual and customary charge for any health care services or the maximum charge established under the rules adopted pursuant to subsection 1, whichever is less.
3. Limitation on reimbursement. In order to qualify for reimbursement for health care services provided to employees under this Title, health care providers providing individual health care services and courses of treatment may not charge more for the services or courses of treatment for employees than is charged to private 3rd-party pay-ors for similar services or courses of treatment. An employer is not responsible for charges that are determined to be excessive or treatment determined to be inappropriate by an independent medical examiner appointed pursuant to section 312 or by the insurance carrier, self-insurer or group self-insurer pursuant to section 210, subsection 7 or the board pursuant to section 210, subsection 8.
(Emphasis added.)

. Title 22 M.R.S. § 1718 (2007) provides, in relevant part:
§ 1718. Consumer information
Each hospital or ambulatory surgical center licensed under chapter 405 shall maintain a price list of the most common inpatient services and outpatient procedures provided by the licensee.
*4052. Outpatient nonemergent procedures. For outpatient nonemergent procedures for which an individual would not incur a bed charge, the price list must include average charges for the 20 most common surgical and diagnostic procedures, excluding laboratory services.
3. Emergency services.
The hospital or ambulatory surgical center licensed under chapter 405 shall post in a conspicuous place a statement about the availability of the price list as required by this section. Posting of the price list is not required.
The hospital or ambulatory surgical center licensed under chapter 405 shall provide its price list upon request of a consumer.
The price list may include a statement that actual charges may vary depending on individual need and other factors.

. Tide 39-A M.R.S. § 210(2) (2007) provides:
2. Utilization review. For purposes of this section, ''utilization review” means the initial prospective, concurrent or retrospective evaluation by an insurance carrier, self-insurer or group self-insurer of the appropriateness in terms of both the level and the quality of health care and health services provided an injured employee, based on medically accepted standards. Utilization review requires the acquisition of necessary records, medical bills and other information concerning any health care or health services.