Medical fee schedule applies in serious burn treatment: CourtPosted On: Nov. 4, 2019 1:25 PM CST
The Supreme Court of Kansas on Friday ruled that language accidentally included in the state’s medical fee schedule for treatment applies in the treatment of a worker who was seriously injured, whose employer’s workers compensation insurer paid less than 20% of the total hospital bill.
In reversing a state Court of Appeals ruling that found the “medical fee schedule was unreasonable, arbitrary, and capricious because the applicable fee limiting provision had been accidentally created,” the state’s highest court fell in line with both a hearing officer and the Workers Compensation Appeals Board, which both held that the insurer had “appropriately paid the amount required by the schedule for maximum medical fees established by the director of the Division of Workers Compensation,” as documented in Via Christi Hospitals Wichita Inc. v. Kan-Pak LLC, et al., filed in Topeka.
Darin Pinion suffered severe burns while working at Kan-Pak LLC in 2011 and was treated that same year. Via Christi Hospital provided medical treatment in the total billed amount of $1,048,569, documents state.
Kan-Pak's workers compensation insurer was Travelers Indemnity Co. of America, which contracted with Paradigm, an out-of-state corporation that specializes in medical management of complex workers compensation cases, to assume Travelers' obligations for Pinion's past and future medical needs. Of Via Christi's bill, Paradigm paid only $136,451.60 in “purported full payment” under the state’s 2011 Schedule of Medical Fees, according to documents.
A main issue was the language in the fee schedule that states if the “reimbursement exceeds the $60,000 stop-loss threshold, the facility shall be paid billed charges multiplied by 70% or (the reimbursement) whichever is least.” Court documents state the origin of the "whichever is least" language — upon which Paradigm relies for its lowered payment to Via Christi — is “unclear.”
State Workers Compensation Division “(m)eeting minutes contain no indication that anyone within the Division, or advising the Division, had noticed the insertion of this language. The manager of medical services… was responsible for guiding the 2011 maximum fee schedule through the process of adoption… (and) testified during a hearing, the Division's adding of the phrase ‘whichever is least’ would have been a significant enough change to come up as part of the process of adopting the 2011 maximum fee schedule,” documents state “But it was not discussed which, according to her testimony, indicated it was not intended to be there. In fact, no one in the record available to this court explained how this particular language was inserted.”
The board found that the insertion of “whichever is least” to be an accidental insertion, but that it had “no authority to void” the medical fee schedule “amending language to hold in Via Christi’s favor.”
The state Supreme Court unanimously upheld thus rationale, writing: “When regulation’s meaning is clear from the plain language used, court generally should give the regulation its plain-language meaning.”