Yablon v. BUREAU OF WORKERS'COMPENSATION
Docket: 2042 C.D. 2010
Court: Commonwealth Court of Pennsylvania; April 21, 2011; Pennsylvania; State Appellate Court
Dr. Jeffrey Yablon and Dr. Vincent Ferrara appealed a decision by the Bureau of Workers' Compensation Fee Review Hearing Office regarding the downcoding of their bills for Vertebral Axial Decompression (VAX-D) treatment provided to workers' compensation claimants. The insurers, PMA Companies, downcoded the billed procedure from CPT code 97799 (an unlisted code) to CPT code 97012 (mechanical traction) after the 30-day submission period had elapsed. The Providers argued that the insurer's failure to notify them of the downcoding within 30 days barred the insurer from doing so and mandated payment of the full billed amount. The hearing officer found that the downcoding was timely and that the 30-day limitation led only to interest payments to the Providers, not a prohibition on downcoding. On appeal, the Providers contended that the statutory provisions constitute an absolute bar against downcoding after 30 days unless the insurer either pays the billed amount or notifies the provider of the intent to downcode. However, the court clarified that the relevant regulations do not impose a penalty for failing to initiate downcoding procedures within 30 days, but instead, Section 127.210 specifies that interest accrues on late payments, thereby affirming the insurer's right to downcode despite the timing issue. Failing to implement the downcoding procedure results in a penalty equivalent to non-payment of a bill, incurring a 10% interest on the unpaid balance. The hearing officer's decision upholding this penalty is affirmed. The order from the Bureau of Workers' Compensation Fee Review Hearing Office dated September 23, 2010, is confirmed. Medical billing under the Workers' Compensation Act adheres to the HCPCS-HCFA Common Procedure Coding System, which includes both numeric and alphanumeric codes developed at national and state levels. Section 306(f.1)(5) mandates that payments to providers for treatment must be made within 30 days of bill receipt. Regulations specify that an insurer proposing changes to a provider's codes cannot extend this 30-day payment period. The review scope is limited to assessing any constitutional violations or legal errors, ensuring that findings of fact are supported by substantial evidence. Insurers can change a provider's codes if they notify the provider in writing, allow a discussion period, have sufficient information, and ensure consistency with Medicare guidelines. Providers must be given a 10-day response period, and insurers must document the notification date. If an insurer changes a provider's code without adhering to these requirements, the Bureau will favor the provider in fee review applications. Additionally, non-compliance with downcoding regulations leads to disputes being resolved in favor of the provider.