By: Lisa A. Miller, Esquire

Provider files a petition for review of the decision of the Fee Review Hearing Officer affirming a determination by the Fee Review Section that Provider’s application was properly denied due to untimeliness under Section 306(f.1)(5). The Court affirmed this decision.

On May 28, 2010, Provider treated a Claimant with Therapeutic Magnetic Resonance (TMR). Provider billed the Carrier $3,298.00 for the procedure on June 25, 2010.

On October 20, 2011, over a year after Provider submitted the bill to the Carrier, Provider filed an application which was denied on October 27, 2011, because the Application was not filed within the time limits prescribed by Section 306(f.1)(5) of the Act.

The sole issue before the Bureau was the status of the bill provider to submit it to the Insurer between June 25, 2010 and October 20, 2011, when Provider submitted the Application.

Provider presented the testimony of Beth Sharkey, and Insurer presented the testimony of Roxane Lombardi, a representative of Corvel.

Ms. Lombardi testified that Corvel processes all workers’ compensation medical bills for the Insurer. She was familiar with the bills in this matter because Corvel processed the Provider’s bill of June 25, 2010 for a date of service of May 28, 2010 for the amount of $3,298.00 for CPT Code 76498. Code 76498 is designated as “unlisted MRI”.

Corvel received Provider’s Bill, accompanied by medical notes on July 9, 2010, and reviewed same. Based upon a review, Corvel denied the bill as experimental, as per the Medicare guidelines. The denial was communicated to the Provider.
She received the same bill, with the same attached documentation, for the date of service of May 28, 2010, fourteen (14) months later on September 12, 2011. The bill was denied a second time. She received the same bill again, with the same documentation a third time, on October 27, 2011. Corvel denied the bill again.

Ms. Sharkey from the Provider testified that Provider rendered TMR treatments on two dates of service: May 14, 2010 and May 28, 2010. Payment for the date of service of May 14, 2010 was received; no payment has been received for the date of May 28, 2010. She received an explanation of benefits on July 22, 2010, indicating that Corvel was denying payment of September 11, 2011.

She resubmitted the bill a second time, on September 12, 2011, and it was again denied. She re-submitted the bill for the date of service of May 28, 2010 again on October 27, 2011, and again it was denied. An application for a Fee Review was filed on October 21, 2011.

The hearing officer reviewed the documentary evidence and considered the testimony, and found no basis to disturb the administrative determination that Provider’s application for fee review was not timely filed. This was based on the persuasive testimony of Ms. Lombardi from Corvel that the bills for treatment on May 28, 2010 were promptly reviewed and timely denied. The EOB was dated July 22, 2010. The testimony of the Provider that the denial, the EOB was received by the Provider on September 23, 2011 is not trustworthy. During the cross-examination testimony of Ms. Lombardi, the Provider admits engaging in conversation regarding the denial of payment with the claims adjustor on September 29, 2010.

Based on the foregoing, the Hearing Officer affirmed the Administrative Decision of the Bureau to deny the Fee Review Application for untimeliness.

The Bureau found that Ms. Sharkey’s testimony was not credible and the Commonwealth Court was bound by that determination. As a result, the Provider failed to establish that the Application was timely filed since the Provider took no action within thirty days following the notification of zero payment for the treatment rendered on May 28, 2010, Provider also failed to act within the ninety day window following the original date of treatment.

If we were to embrace Provider’s reading of the Act, the thirty and ninety day windows provided in the statute would be rendered mere surplus, as a Provider could simply submit the bill ad infinitum with the hope that the Insurer may treat it differently in the future, however distant.

Section 306(f.1)(5) does not allow a Provider to open another thirty day window simply by resubmitting a properly documented bill that has already been denied; the regulation promulgated under the Act allowing the Provider the greater of the thirty or ninety day window offers a fair opportunity to seek review of an Insurer’s action, but neither the statutory text nor the regulations relieve Providers of the duty to seek redress from the Fee Review process in a timely fashion.