An insurer cannot rely on an outside database to reduce reimbursement paid to a trauma care provider for an employee’s injuries under the Workers’ Compensation Act, the Commonwealth Court has ruled.
A unanimous three-judge panel ruled July 6 in Allegheny General Hospital v. Bureau of Workers’ Compensation Fee Review Hearing Office that a medical fee hearing officer relied on a database without accurate information on the “usual and customary charge” for trauma care charges at providers in the same geographic region. The court reversed the decision and remanded for a determination of the usual charges, while also denying the provider’s request to be reimbursed at 100 percent of its actual charges.
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