ILNews

Judges rule on workers' comp billing issues

Back to TopCommentsE-mailPrintBookmark and Share

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The other two unpublished opinions dealt with similar issues, one involving a Michigan City employee who received care at Memorial Hospital of South Bend, and the other an Onward Fire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

ADVERTISEMENT

Post a comment to this story

COMMENTS POLICY
We reserve the right to remove any post that we feel is obscene, profane, vulgar, racist, sexually explicit, abusive, or hateful.
 
You are legally responsible for what you post and your anonymity is not guaranteed.
 
Posts that insult, defame, threaten, harass or abuse other readers or people mentioned in Indiana Lawyer editorial content are also subject to removal. Please respect the privacy of individuals and refrain from posting personal information.
 
No solicitations, spamming or advertisements are allowed. Readers may post links to other informational websites that are relevant to the topic at hand, but please do not link to objectionable material.
 
We may remove messages that are unrelated to the topic, encourage illegal activity, use all capital letters or are unreadable.
 

Messages that are flagged by readers as objectionable will be reviewed and may or may not be removed. Please do not flag a post simply because you disagree with it.

Sponsored by
ADVERTISEMENT
Subscribe to Indiana Lawyer
  1. How nice, on the day of my car accident on the way to work at the Indiana Supreme Court. Unlike the others, I did not steal any money or do ANYTHING unethical whatsoever. I am suing the Indiana Supreme Court and appealed the failure of the district court in SDIN to protect me. I am suing the federal judge because she failed to protect me and her abandonment of jurisdiction leaves her open to lawsuits because she stripped herself of immunity. I am a candidate for Indiana Supreme Court justice, and they imposed just enough sanction so that I am made ineligible. I am asking the 7th Circuit to remove all of them and appoint me as the new Chief Justice of Indiana. That's what they get for dishonoring my sacrifice and and violating the ADA in about 50 different ways.

  2. Can anyone please help this mother and child? We can all discuss the mother's rights, child's rights when this court only considered the father's rights. It is actually scarey to think a man like this even being a father period with custody of this child. I don't believe any of his other children would have anything good to say about him being their father! How many people are afraid to say anything or try to help because they are afraid of Carl. He's a bully and that his how he gets his way. Please someone help this mother and child. There has to be someone that has the heart and the means to help this family.

  3. I enrolled America's 1st tax-free Health Savings Account (HSA) so you can trust me. I bet 1/3 of my clients were lawyers because they love tax-free deposits, growth and withdrawals or total tax freedom. Most of the time (always) these clients are uninformed about insurance law. Employer-based health insurance is simple if you read the policy. It says, Employers (lawyers) and employees who are working 30-hours-per-week are ELIGIBLE for insurance. Then I show the lawyer the TERMINATION clause which states: When you are no longer ELIGIBLE! Then I ask a closing question (sales term) to the lawyer which is, "If you have a stroke or cancer and become too sick to work can you keep your health insurance?" If the lawyer had dependent children they needed a "Dependent Conversion Privilege" in case their child got sick or hurt which the lawyers never had. Lawyers are pretty easy sales. Save premium, eliminate taxes and build wealth!

  4. Ok, so cheap laughs made about the Christian Right. hardiharhar ... All kidding aside, it is Mohammad's followers who you should be seeking divine protection from. Allahu Akbar But progressives are in denial about that, even as Europe crumbles.

  5. Father's rights? What about a mothers rights? A child's rights? Taking a child from the custody of the mother for political reasons! A miscarriage of justice! What about the welfare of the child? Has anyone considered parent alienation, the father can't erase the mother from the child's life. This child loves the mother and the home in Wisconsin, friends, school and family. It is apparent the father hates his ex-wife more than he loves his child! I hope there will be a Guardian Ad Litem, who will spend time with and get to know the child, BEFORE being brainwashed by the father. This is not just a child! A little person with rights and real needs, a stable home and a parent that cares enough to let this child at least finish the school year, where she is happy and comfortable! Where is the justice?

ADVERTISEMENT