PORTLAND, June 2003–Qmedtrix Systems, Inc.'s methodology for reviewing outpatient surgery center facility fees was validated once again when the State of California Court of Appeal upheld the Workers' Compensation Appeals Board's decision in Kunz v. Patterson Floor Coverings, Inc. (2002) 67 CCC 1588. The case established precedent on outpatient facility fees and lien claim issues for workers' compensation in the absence of a fee schedule.
According to the WCAB's decision, fees for outpatient surgery facilities must be reasonable. To determine that, the court may take into account:
- Fees charged
by other medical providers in the area, as well as the providing facility's
fees.
- The amounts
usually accepted, not the fees charged, by the providing facility and
other providers in the same area, including in-patient providers.
- Fees accepted
for both workers' compensation and non-workers' compensation claims,
including contractually negotiated fees.
- Whether
the bills were properly documented.
- Other economic factors as deemed appropriate by the Board.
The WCAB's ruling also determined that a defendant's failure to specifically object to a medical treatment lien claim does not constitute a waiver of that objection.
Alpine Surgery Centers, LP, dba Silicon Valley Surgery Center ("Alpine"), an outpatient surgical facility, filed a Petition for Writ of Review the WCAB's En Banc decision. Alpine's Petition was dismissed May 27, 2003.
Alpine's
original case was based on the insurer's decision to only reimburse the
surgery center the portion of the bill deemed fair and reasonable after
a comprehensive review by Qmedtrix Systems, Inc. Qmedtrix's method of
review includes all of the factors established as reasonable by the Appeals
Board.
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