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Health care provider timely filed claim.

Byline: Virginia Lawyers Weekly

Because the employer contested payment for a portion of health care services provided to an employee, the provider had one year from the date on which the final medical award to the injured claimant was issued to file its claim. Because the provider filed its claim within the one year, it was timely.

Background

On Feb. 23, 2015, Jeffrey Boyer was injured while in the employ of Bimbo Bakeries USA Inc. Roanoke Ambulatory Surgery Center provided treatment to Boyer for his injuries. RASC subsequently submitted a bill of $23,122 to Bimbo Bakeries. On June 12, 2015, Bimbo Bakeries delivered payment of $4,863.10 to RASC. Bimbo Bakeries also delivered a document labeled "Review Analysis" to RASC that detailed the amount it was paying for Boyer's surgery and included, among other things, the following statements: "Recommended allowance is considered fair & reasonable based on an analysis performed in your geographical area. . . . A technical Bill Review (TBR) has been performed. . . . Amounts billed above the recommended allowance are hereby objected to as being in excess of the amounts authorized under state law."

After RASC performed a second surgery on Boyer's shoulder, it submitted a bill of $12,101 to Bimbo Bakeries. On Oct. 30, 2015, Bimbo Bakeries delivered payment of $3,078.81 for the second surgery. Bimbo Bakeries also provided a "Review Analysis" document related to the second surgery that contained the same language quoted above from its first review analysis. Bimbo Bakeries made no further payments to RASC for either of the two surgeries.

Boyer eventually submitted a timely claim to the commission on June 27, 2016, for workers' compensation benefits related to his February 2015 injury. On July 28, 2017, the commission approved an agreement between Boyer and Bimbo Bakeries that included an award in favor of Boyer for lifetime medical benefits for treatment of his right shoulder rotator cuff injury.

RASC then filed a claim with the commission requesting full payment for the medical services it provided to Boyer. Concluding RASC's claim was not time barred and since Bimbo Bakeries did not meet its burden of proving that the medical fees were excessive, the deputy commissioner awarded RASC the balance of its charges from both surgeries that had not been paid $27,281.09.

The full commission reversed, concluding RASC's filing of its claim was time barred pursuant to Virginia Code 65.2-605.1(F)(i).

Analysis

The disposition of this case comes down entirely to whether RASC's claim was time barred, since there is nothing in the record before us to show that Bimbo Bakeries has, at any time, presented any evidence to the commission or to this court to rebut RASC's evidence that the charges were reasonable and necessary.

There is no question that RASC's claim would be time barred if subsection (i) of Code 65.2-605.1(F) governs this factual scenario because it clearly states that a claim is barred unless filed within one year of the last payment received by the health care provider.

However, if subsection (ii) governs this situation, the result is different. Subsection (ii) applies "if the employer denied or contested payment for any portion of the health care services." Bimbo Bakeries clearly contested payment for the amount billed beyond the small percentage of the bill for each surgery that Bimbo Bakeries actually paid. Because the employer "denied or contested payment," subsection (ii) applies in this situation.

The commission's (and Bimbo Bakeries') interpretation of the statute turning upon whether the payments are made voluntarily is simply unpersuasive. Nowhere in Code 65.2-605.1(F) is voluntariness discussed, and nowhere in it does the word "voluntary" even appear. Nor is such an interpretation in keeping with a plain reading of the statute.

According to the plain reading of Code 65.2-605.1(F)(ii), RASC had one year under subsection (ii) from the date on which the final medical award to the injured claimant was issued to file its claim. The commission issued an order granting an award to claimant Boyer on July 28, 2017. RASC filed its claim on Sept. 1, 2017 easily within the one-year deadline for a health care provider to file a claim under this scenario, according to the requirements of subsection (F)(ii) of the statute.

The commission's decision is therefore reversed and the matter is remanded to the commission for it to enter an award to RASC of the balance of its unpaid charges $27,281.09, in addition to interest at the judgment rate.

Reversed and remanded.

Roanoke Ambulatory Surgery Center v. Bimbo Bakeries USA Inc., Record No. 1055-18-2, Jan. 29, 2019. CAV (Beales) from Workers' Compensation Commission. Cheri Hodges Warren for Appellant, Emily S. Kirkpatrick for Appellees. VLW No. 019-7-019, 9 pp.

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Title Annotation:Roanoke Ambulatory Surgery Center v. Bimbo Bakeries USA Inc., Virginia Court of Appeals
Publication:Virginia Lawyers Weekly
Date:Feb 10, 2019
Words:801
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