Court Opinion

ID: 9694437
Source: CourtListenerOpinion
Date Created: 2023-08-25 17:41:46.270473+00
Date Added: 2024-06-11T18:20:01.485824
License: Public Domain

DISSENTING OPINION BY
Judge LEAVITT.
Respectfully, I dissent. In this case of first impression, the Court holds that an employer can be required to pay attorney fees if the employer fails to prove that a course of medical treatment is not reasonable or necessary. I do not believe the General Assembly has authorized the payment of such fees anywhere in the Workers’ Compensation Act (Act), Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §§ 1-1041.4, 2501.2626.
In this case, Employer challenged an ongoing course of chiropractic treatment for Claimant’s low back strain. Consistent with the Act, Employer sought a utilization review from a licensed URO, which assigned the matter to a review by Louis Camilli, D.C., another chiropractor. Dr. Camilli determined that Claimant’s chiro*828practic treatment was reasonable and should continue indefinitely into the future. Employer appealed on November 17, 2000, and its appeal was assigned to a WCJ on December 1, 2000.1 On February 15, 2001, W. Brett Carothers, D.C., conducted an independent chiropractic examination of Claimant. Dr. Carothers concluded that Claimant’s therapy, which consisted of lying on a roller bed and having a “thumper clicker” applied to the low back, was no longer reasonable or necessary. Reproduced Record at 67a (R.R. _). This kind of passive, in-office therapy, in the opinion of Dr. Carothers, was not what Claimant needed; rather, he needed an active, home-based course of therapy. Further, the therapy gave Claimant, at best, only .temporary relief. It is uncontested that Dr. Carothers’ opinion was sufficient to make Employer’s appeal of the URO determination a reasonable one, at least as of February 15, 2001. Notably, Employer obtained Dr. Carothers’ opinion within 90 days of its appeal, in spite of the fact that Claimant resisted the examination and attended it only after being ordered to do so by the WCJ. Employer was neither dilatory nor vexatious in seeking a review of the reasonableness of Claimant’s medical treatment.
The Act includes several measures designed to resolve workers’ compensation claims promptly and fairly. For example, a WCJ may impose penalties upon an employer who violates the Act. See Section 435 of the Act, 77 P.S. § 991. Another example is the WCJ’s authority to impose costs. Section 440(a) of the Act, 77 P.S. § 996(a), authorizes a WCJ to order an insurer to pay “the employee or his dependent, as the case may be, ... a reasonable sum ... for attorney’s fees” unless the insurer establishes “a reasonable basis for the contest.”2 This measure discourages employers from using litigation to delay payment of a valid compensation claim. However, Section 440(a) applies only to litigation of compensation awards and not to utilization review litigation. This is logical because of the fundamental difference between a contest of a compensation award and a contest over a particular provider’s invoice.
Utilization review was established as part of a legislative program intended to control the medical costs associated with workers’ compensation. To that end, Section 306(f.l) of the Act, 77 P.S. § 531, instituted, inter alia, the following: a cap on the amount that can be charged by a provider; a requirement that employees visit an employer’s authorized panel of *829physicians; and peer review of provider services by a licensed URO. Section 306(f.l), which is a self-contained regime, makes no mention of awarding attorney fees in the case where an employer’s appeal of a URO determination is found to be unreasonable to a claimant or provider. Further, even though Section 306(f.l) makes several references to other statutes and to other provisions of the Act, it does not refer to Section 440(a) of the Act, 77 P.S. § 996(a).
Utilization review is narrow in scope. It pertains to a provider’s course of treatment, and it has no impact on the claimant’s award for medical benefits.3 Utilization review is available only where the employer’s liability for a claimant’s medical treatment has already been established; its purpose is to permit oversight of the treatment of an injury. Utilization review may be initiated by an employer, provider or an employee. The challenge is initiated by requesting review from a URO, which is a private organization licensed by the Commonwealth; the URO then assigns the request to a provider who specializes in the same medical specialty as the provider being reviewed. Notably, the cost of the URO must be borne by the employer, even when the review is sought by the employee. Any person affected by the URO’s determination, including a provider, may appeal to a WCJ and must do so promptly, ie., within 30 days of receiving the URO determination.4
The majority believes that Employer’s contest was unreasonable because it did not obtain the opinion of Dr. Carothers before appealing Dr. Camilli’s determination. Apart from the fact that it is unreasonable to expect that Employer could have done so within 30 days, attorney fees are not authorized.
Section 440(a) does not cover appeals of URO determinations. First, Section 440(a) does not identify a utilization review petition as one of the petitions that can trigger an award of costs, including attorney fees. Second, Section 440(a) authorizes an award of costs to “an employee or dependent,” but not to a “provider,” in spite of the fact that the provider can be the party adverse to an employer in a utilization review petition. This omission of providers also supports the inference that Section 440(a) does not apply to utilization review controversies. Stated otherwise, by its plain terms, Section 440(a) applies only to petitions that relate to compensation awards and not to utilization review petitions.
If the legislature had intended to authorize an award of costs in a URO appeal, it would have so stated in Section 306(f.l) or in Section 440(a). It did not, and there are reasons that explain this policy decision. There is less at stake in utilization review, ie., one or several medical bills, not the ability to receive medical treatment for a work-related injury. Second, the claimant is not liable for a provider’s bill should the employer prevail in a utilization *830review appeal. Act 44 prohibits providers from holding employees financially liable for treatment later determined unreasonable.5 See Section 306(f.l)(7), 77 P.S. § 531(7).6 Third, Section 306(f.l) builds in a disincentive against an employer invoking utilization review without having reasonable grounds: the employer bears the costs of this review even where it is initiated by the employee. Section 306(f.l)(6)(iii), 77 P.S. § 531(6)(iii).7 The reality is that medical invoices are reviewed by professional claims adjusters with expertise in claims; they will not incur the cost of the peer review provided by a URO organization without having some reason to do so.
In short, unlike the majority, I believe the Act does not authorize an award of attorney fees in the case of a utilization review. Section 306(f.l), the logical place for such authorization is silent, and Section 440(a) of the Act applies to compensation litigation, not to utilization review. Even assuming, arguendo, that Section 440(a) does apply in a utilization review proceeding, I agree with Employer that it did not need a medical opinion in its favor prior to appealing the determination of a URO in order for its appeal to be reasonable.
As noted by the majority, this Court has held on numerous occasions that where an employer’s contest is based upon an expert medical opinion that was acquired after a contest is initiated, the contest will be found unreasonable, at least up to the point the opinion was obtained. Jones & Laughlin Steel Corp. v. Workmen’s Compensation Appeal Board (White), 92 Pa.Cmwlth.318, 500 A.2d 494 (1985). There are several reasons why the Jones & Laughlin principle should not be applied in the case of an appeal of a URO determination.
First, the risk of a frivolous URO appeal is low. It is the employer’s burden to show at the hearing before the WCJ that medical treatment is neither reasonable nor necessary. This burden is not likely to be met without presenting expert testimony; accordingly, when an employer appeals to a WCJ, it does so knowing that it must incur the expense of an expert. It seems unlikely that employers will incur this cost lightly, when, after all, the matter at issue is not an entire compensation award but a provider’s treatment. In other words, the cost of litigation is high relative to a successful outcome, i.e., relief from liability for a provider’s treatment.
Second, the time constraints for a URO review are tight. An employer, insurer, provider or employee has thirty days to appeal an adverse determination of a URO.8 This is too short a period of time in which to obtain an expert opinion on the merits of a URO determination. To issue an ipse dixit rule that it is unreasonable for an employer to seek review without first having an expert opinion in hand has *831overly burdensome consequences. It will mean that the expert opinion must be sought prior to initiating the utilization review because there will be no time after-wards to obtain it. This is redundant because the employer is already paying for the expert opinion provided by the URO. Further, it will mean that the employer, who has to pay for the URO review initiated by an employee, will have to engage the advice of a medical expert even when the utilization review is initiated by the employee, just in case the determination is adverse to the employer.9 These consequences turn the cost saving objective of Section 306(f.l) on its head.
Jones & Laughlin established a judge-made rule that a contest to an award of medical benefits is per se unreasonable unless a medical opinion is obtained prior to initiating this contest. The rule does not fit into the utilization review scheme.10 The time limits and risks involved in utilization review are completely different from those involved in a contest over an award of compensation. Accordingly, even if Section 440(a) of the Act allows for the imposition of attorney fees in a utilization review, the standard for measuring “reasonableness” should be a different one than that established in Jones & Laughlin for compensation contests.
Provider oversight is an important aspect to cost containment, and this goal is not advanced by encumbering utilization review with redundant medical opinions. Because Section 306(f.l) does not authorize the imposition of attorney fees in a utilization review and Section 440(a) of the Act applies to compensation awards, not to whether a provider’s treatment is reasonable and necessary, I believe the WCJ erred.
Accordingly, I would reverse.
Judge COHN JUBELIRER joins in this dissent.

. The WCJ stated in her opinion that "[t]he Utilization Review Petition was assigned to this [WCJ] on March 2, 2000.” WCJ Opinion at 1. The certified record indicates that the date of assignment was December 1, 2000.

. Section 440(a) states in full:
(a) In any contested case where the insurer has contested liability in whole or in part, including contested cases involving petitions to terminate, reinstate, increase, reduce or otherwise modify compensation awards, agreements or other payment arrangements or to set aside final receipts, the employe or his dependent, as the case may be, in whose favor the matter at issue has been finally determined in whole or in part shall be awarded, in addition to the award for compensation, a reasonable sum for costs incurred for attorney’s fee, witnesses, necessary medical examination, and the value of unreimbursed lost time to attend the proceedings: Provided, That costs for attorney fees may be excluded when a reasonable basis for the contest has been established by the employer or the insurer.
77 P.S. § 996(a) (emphasis added). The list does not include petitions to review a determination of a URO. Whether or not a provider’s invoice will be paid is not a modification of a compensation award; the compensation award remains intact notwithstanding a utilization review.

. Indeed, utilization review is not properly invoked where the employer disputes liability for medical treatment for the reason that it is not causally related to the original work-related injury; such a challenge must be addressed to a WCJ. Bloom v. Workmen’s Compensation Appeal Board (Keystone Pretzel Bakery), 677 A.2d 1314 (Pa.Cmwlth.1996).

. A WCJ may not consider a claim that there has been an overcharge or inappropriate treatment unless a URO review has been done. Further, if a timely appeal is not filed, a WCJ is bound by the URO determination even if evidence in another proceeding shows that the URO erred. Further, the parties by stipulation cannot agree to bypass URO review and proceed directly to a WCJ. Zuver v. Workers' Compensation Appeal Board (Browning Ferris Industries of PA, Inc.), 755 A.2d 112 (Pa.Cmwlth.2000).

. By contrast, until such time as a claimant establishes a right to medical compensation benefits, he is responsible for the cost of his treatment.

. It states:
(7) A provider shall not hold an employe liable for costs related to care or service rendered in connection with a compensable injury under this act. A provider shall not bill or otherwise attempt to recover from the employe the difference between the provider's charge and the amount paid by the employer or the insurer.
77 P.S. §531(7).

. It states:
(iii) The employer or the insurer shall pay the cost of the utilization review.
77 P.S. § 531(6)(iii).

. Of course, this raises the question why a provider or a claimant ought not to have an expert opinion in hand when one of them appeals the determination of a URO.

. The majority observes that utilization review involves a two-step process: (1) a utilization review request, which leads to a URO determination, and (2) an appeal from the URO determination to a WCJ. The majority stresses that an employer can avail itself of the first "step” without presenting (or even having) medical evidence. Consequently, if an employer proceeds to the second "step,” which the majority characterizes as a "contest," the employer must have an evidentiary basis for doing so. I am not persuaded by this attempt to put the cart before the horse. An employer’s initial utilization review request may be based on little more than suspicions that a claimant’s medical treatment is no longer reasonable or necessary. At this preliminary stage of the utilization review process, the employer is still assessing its position and would have no reason to incur the expense of deposing an expert until after the determination is rendered.

. A dispute over eligibility for compensation may be based on numerous grounds ranging from whether the injury occurred at work to whether the injured worker was even an employee, as opposed to an independent contractor. Only those contests that involve a medical opinion will implicate the Jones & Laughlin rule. By contrast, each and every utilization review involves a medical opinion.