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Pennsylvania court to decide if pharmacists have right to intervene in utilization

Workers Comp

The Pennsylvania Supreme Court has agreed to hear a case challenging a court decision holding that pharmacists had the right to intervene in the workers compensation utilization review process.

In Keystone Rx LLC v. Bureau of Workers Compensation Fee Review Office, the court on Sept. 1 agreed to answer the question of whether the Pennsylvania Commonwealth Court exceeded its authority when it held that non-treating providers, such as pharmacists, have a right to intervene in the utilization review process.

In 2017, a workers compensation claimant was prescribed medications that were dispensed by Keystone Rx and billed to the insurer, which filed a utilization review request and ultimately determined that the medications were unnecessary. Keystone filed two applications for fee review for the $3,616 for compound cream and $887 for Naprelan tablets it dispensed to the worker at the doctor’s request. The hearing office dismissed the applications. The pharmacy petitioned the Commonwealth Court for review of the dismissal.

The court held that the Pennsylvania Workers Compensation Act allows a pharmacist to challenge only the amount and timeliness of the payment from the insurer or employer, but not reasonableness or necessity of treatment, which are subject to utilization review at the direction of the employer, insurer or employee. The court also said that a hearing office did have the jurisdiction to determine whether a pharmacist was a health care provider, but noted that its decision did not “expand the scope of the fee review proceeding beyond timeliness and amount owed to a provider that has treated a claimant for his work injury” and affirmed the hearing officer’s dismissal of the pharmacy’s application for fee review.

However, the court acknowledged that there are due process issues for pharmacists who are precluded from participating in the utilization review process yet are bound by the results, and declared a new rule going forward that utilization review procedures occurring after the date of the opinion must afford pharmacists, testing facilities or medical supply providers notice and an opportunity to intervene.

The pharmacy appealed to the Pennsylvania Supreme Court, which will decide whether the Commonwealth Court “violated the separation of powers doctrine” by creating a requirement that pharmacies and other non-treating providers be given notice and an opportunity to intervene in the utilization review process of its comp clients.