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Payment claim for injured worker’s surgeries not time-barred

Payment claim for injured worker’s surgeries not time-barred

A surgery center’s claim seeking payment for two surgeries it performed on an injured worker was not time-barred, according to the Virginia Court of Appeals.

In Roanoke Ambulatory Surgery Center v. Bimbo Bakeries USA Inc., the appeals court in Richmond, Virginia, on Tuesday reversed a decision by the state’s Workers Compensation Commission that held that the Roanoke Ambulatory Surgery Center in Roanoke, Virginia, failed to submit its claim for full compensation of two shoulder rotator cuff surgeries it performed on an injured worker within the one-year statute of limitations.

The employee injured his right shoulder during the course of his work at Bimbo Bakeries, based in Horsham Township, Pennsylvania. On April 29, 2015, he underwent surgery at the Roanoke Ambulatory Surgical Center to repair the injury and had a second surgery performed at the center on Sept. 18, 2015. The surgery center submitted a bill of $23,122 to Bimbo Bakeries for the first surgery and $12,101 for the second. On June 12, 2015, Bimbo Bakeries paid the center $4,863 for the first bill, and included a “review analysis” document stating that the payment was fair and reasonable “based on an analysis performed in your geographical area.” The document also said that “(a)mounts billed above the recommended allowance are hereby objected to as being in excess of the amounts authorized under state law.” It paid the surgery center $3,078.81 on Oct. 30, 2017 for the second surgery and included another review analysis document containing the same language as the prior document.

On June 27, 2016, the employee submitted a claim to the Virginia Workers Compensation Commission for benefits relating to his injury. On July 28, 2017, the commission approved an agreement between the employee and Bimbo Bakeries, which awarded him lifetime benefits for treatment of his shoulder rotator cuff injury.

On Sept. 1, 2017, the surgery center filed a claim with the commission requesting full payment for the medical services it provided. The deputy commissioner found that the surgery center’s claim was not time-barred and that Bimbo Bakeries did not produce any evidence to rebut the surgery center’s evidence that its charges were reasonable and necessary. She awarded the surgery center the balance of its charges from both surgeries, which totaled $27,281.09.

Bimbo Bakeries sought a review by the commission, which reversed the award to the surgery center, holding that its claim was time-barred. The surgery center appealed the decision.

The surgery center alleged that the statute contains two separate statutes of limitations and conceded that its claim would have been time-barred under the first part, which states that the claim must be filed within one year of the date of the last payment it received by the health care provider, but argued that it filed its claim within the time restrictions in the second part of the statute.

The appellate court noted that the second section includes the language “if the employer denied or contested payment for any portion of the health care services” then the claim must be filed one year from the date on which the final medical award to the injured claimant was issued. Since the commission granted the award to the employee on July 28, 2017, the court found that the surgery center’s filing of its claim on Sept. 1, 2017, was “easily within the one-year deadline” according to the second part of the statute.

The court held that the commission erred as a matter of law in its interpretation of the statute and reversed the decision, awarding the surgery center the balance of the unpaid charges as well as interest.

Roanoke Ambulatory Surgery Center declined to comment. Bimbo Bakeries did not respond to a request for comment.




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