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Judges rule on workers' comp billing issues

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Employers or their insurers - not health care providers - must prove when medical expenses for injured employees might be considered higher than what's allowed under the state's workers' compensation statute, according to the Indiana Court of Appeals.

In a series of rulings today that deal with injured firefighters and city workers in multiple Hoosier communities, a three-judge appellate panel interpreted the Indiana Workers' Compensation Act and how it applies to state statutes about medical billing disputes.

"This case requires us to review several statutes under the Act that balance the right of medical service providers to seek payment for medical care to injured workers, against the right of employers to demand that such payments not be excessive," the unanimous panel wrote, turning to its own Indiana precedent as well as rulings from other state and federal courts.

The cases are Washington Township Fire Department v. Beltway Surgery Center, No. 93A02-0811-EX-01006; City of Michigan City v. Memorial Hospital, No. 93A02-0811-EX-01010; and Onward Fire Department v. Clarian Health Partners, No. 93A02-0811-EX-01007. Three other suits on identical issues, filed the same day in November and assigned to the same writing panel of judges, were handed down June 25. They are Adecco Inc. v. Clarian Health Partners, No. 93A02-0811-EX-1008; Morgan County Commissioners v. Clarian Health Partners, No. 93A02-0811-EX-1009; and Wayne Township Fire Department v. Beltway Surgery Center, No. 93A02-0811-EX-1011.

The Washington case handed down June 24 dealt with medical provider Beltway Surgery Center, specifically involving about $11,563 in billed medical care that an injured firefighter received in March 2005 after sustaining injuries on the job. The township's workers' compensation insurer hired a billing review service as allowed by the Indiana Workers' Compensation Act, and that service determined the surgery center was charging too much - it didn't fall below a standard 80th percentile, the maximum amount an employer's "pecuniary liability" can be for medical services under the act. That service recommended that only about $5,104 be paid, and Beltway Surgery took the case to the compensation board to recover the remaining unpaid amount it had billed.

The other two unpublished opinions dealt with similar issues, one involving a Michigan City employee who received care at Memorial Hospital of South Bend, and the other an Onward Fire Department employee who received care at Clarian Health Partners.

With the lead and only published opinion of Washington, the panel unanimously determined that if an employer or its insurer refuses to pay the full amount of a medical service provider's bill, then the employer must prove before the Indiana Workers' Compensation Board that its pecuniary liability to that provider is less than the billed charges. The judges also held that if an employer fails to prove how a billing review service calculated that the amount exceeded the 80th percentile standard, then the board could order the employer to pay the full amount of the submitted bill.

"We conclude that placing the burden of proof on the employer is more consistent with Indiana law generally and with the Act itself," the court wrote. "The 80th percentile rule is a more precise codification of the general principle that medical bills sought to be recovered during litigation be reasonable and not be excessive."

Since employers or their insurers are allowed to hire billing review companies, then those reviewers should be capable of offering proof as to why a billed amount might be considered excessive, the court wrote. To conclude otherwise and require doctors or hospitals to prove why their bills aren't excessive would presume that happens more often than not and might stop medical service providers from providing that care to injured workers, out of fear they might not get fully paid.

"The value of such assurance of payment as an incentive for medical service providers to treat injured workers under the Act would be greatly diminished if employers, their insurers, and billing review services were permitted to make unilateral decisions to pay providers less than the amount of their billed charges without being required to prove the validity of such a reduction," the court wrote.

It would be up to the General Assembly to amend statute so that medical providers bear the burden of establishing that their bills fall outside that guideline, the judges determined.

The panel affirmed each of the decisions by the Workers' Compensation Board to place the burden on employers, and award the full amount of billed charges.

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  1. Call it unauthorized law if you must, a regulatory wrong, but it was fraud and theft well beyond that, a seeming crime! "In three specific cases, the hearing officer found that Westerfield did little to no work for her clients but only issued a partial refund or no refund at all." That is theft by deception, folks. "In its decision to suspend Westerfield, the Supreme Court noted that she already had a long disciplinary history dating back to 1996 and had previously been suspended in 2004 and indefinitely suspended in 2005. She was reinstated in 2009 after finally giving the commission a response to the grievance for which she was suspended in 2004." WOW -- was the Indiana Supreme Court complicit in her fraud? Talk about being on notice of a real bad actor .... "Further, the justices noted that during her testimony, Westerfield was “disingenuous and evasive” about her relationship with Tope and attempted to distance herself from him. They also wrote that other aggravating factors existed in Westerfield’s case, such as her lack of remorse." WOW, and yet she only got 18 months on the bench, and if she shows up and cries for them in a year and a half, and pays money to JLAP for group therapy ... back in to ride roughshod over hapless clients (or are they "marks") once again! Aint Hoosier lawyering a great money making adventure!!! Just live for the bucks, even if filthy lucre, and come out a-ok. ME on the other hand??? Lifetime banishment for blowing the whistle on unconstitutional governance. Yes, had I ripped off clients or had ANY disciplinary history for doing that I would have fared better, most likely, as that it would have revealed me motivated by Mammon and not Faith. Check it out if you doubt my reading of this, compare and contrast the above 18 months with my lifetime banishment from court, see appendix for Bar Examiners report which the ISC adopted without substantive review: https://www.scribd.com/doc/299040839/2016Petitionforcert-to-SCOTUS

  2. Wow, over a quarter million dollars? That is a a lot of commissary money! Over what time frame? Years I would guess. Anyone ever try to blow the whistle? Probably not, since most Hoosiers who take notice of such things realize that Hoosier whistleblowers are almost always pilloried. If someone did blow the whistle, they were likely fired. The persecution of whistleblowers is a sure sign of far too much government corruption. Details of my own personal experience at the top of Hoosier governance available upon request ... maybe a "fake news" media outlet will have the courage to tell the stories of Hoosier whistleblowers that the "real" Hoosier media (cough) will not deign to touch. (They are part of the problem.)

  3. So if I am reading it right, only if and when African American college students agree to receive checks labeling them as "Negroes" do they receive aid from the UNCF or the Quaker's Educational Fund? In other words, to borrow from the Indiana Appellate Court, "the [nonprofit] supposed to be [their] advocate, refers to [students] in a racially offensive manner. While there is no evidence that [the nonprofits] intended harm to [African American students], the harm was nonetheless inflicted. [Black students are] presented to [academia and future employers] in a racially offensive manner. For these reasons, [such] performance [is] deficient and also prejudice[ial]." Maybe even DEPLORABLE???

  4. I'm the poor soul who spent over 10 years in prison with many many other prisoners trying to kill me for being charged with a sex offense THAT I DID NOT COMMIT i was in jail for a battery charge for helping a friend leave a boyfriend who beat her I've been saying for over 28 years that i did not and would never hurt a child like that mine or anybody's child but NOBODY wants to believe that i might not be guilty of this horrible crime or think that when i say that ALL the paperwork concerning my conviction has strangely DISAPPEARED or even when the long beach judge re-sentenced me over 14 months on a already filed plea bargain out of another districts court then had it filed under a fake name so i could not find while trying to fight my conviction on appeal in a nut shell people are ALWAYS quick to believe the worst about some one well I DID NOT HURT ANY CHILD EVER IN MY LIFE AND HAVE SAID THIS FOR ALMOST 30 YEARS please if anybody can me get some kind of justice it would be greatly appreciated respectfully written wrongly accused Brian Valenti

  5. A high ranking Indiana supreme Court operative caught red handed leading a group using the uber offensive N word! She must denounce or be denounced! (Or not since she is an insider ... rules do not apply to them). Evidence here: http://m.indianacompanies.us/friends-educational-fund-for-negroes.364110.company.v2#top_info

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