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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The other two unpublished opinions dealt with similar issues, one involving a Michigan City employee who received care at Memorial Hospital of South Bend, and the other an Onward Fire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. Such things are no more elections than those in the late, unlamented Soviet Union.

  2. It appears the police and prosecutors are allowed to change the rules halfway through the game to suit themselves. I am surprised that the congress has not yet eliminated the right to a trial in cases involving any type of forensic evidence. That would suit their foolish law and order police state views. I say we eliminate the statute of limitations for crimes committed by members of congress and other government employees. Of course they would never do that. They are all corrupt cowards!!!

  3. Poor Judge Brown probably thought that by slavishly serving the godz of the age her violations of 18th century concepts like due process and the rule of law would be overlooked. Mayhaps she was merely a Judge ahead of her time?

  4. in a lawyer discipline case Judge Brown, now removed, was presiding over a hearing about a lawyer accused of the supposedly heinous ethical violation of saying the words "Illegal immigrant." (IN re Barker) http://www.in.gov/judiciary/files/order-discipline-2013-55S00-1008-DI-429.pdf .... I wonder if when we compare the egregious violations of due process by Judge Brown, to her chiding of another lawyer for politically incorrectness, if there are any conclusions to be drawn about what kind of person, what kind of judge, what kind of apparatchik, is busy implementing the agenda of political correctness and making off-limits legit advocacy about an adverse party in a suit whose illegal alien status is relevant? I am just asking the question, the reader can make own conclsuion. Oh wait-- did I use the wrong adjective-- let me rephrase that, um undocumented alien?

  5. of course the bigger questions of whether or not the people want to pay for ANY bussing is off limits, due to the Supreme Court protecting the people from DEMOCRACY. Several decades hence from desegregation and bussing plans and we STILL need to be taking all this taxpayer money to combat mostly-imagined "discrimination" in the most obviously failed social program of the postwar period.

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