The Missouri Court of Appeals upheld an order from the Labor and Industrial Relations Commission ordering an insurer to pay the full amount billed by a treatment provider for an injured worker’s knee surgery.
An employee of S&B Hauling & Construction suffered a knee injury at work in July 2020. S&B’s insurance carrier authorized The Center for Surgical Specialties PC to perform arthroscopic surgery to repair the employee’s knee, according to S&B Hauling & Construction v. Center for Surgical Specialties PC, filed Dec. 2.
Surgical Specialties billed the insurer $19,763 for its services. The insurer paid Surgical Specialties $11,566.52 but refused to pay the remaining balance.
Surgical Specialties filed an application with the Workers’ Compensation Division for payment of the balance. The insurer responded that the amount already paid to Surgical Specialties represented the usual and customary rate for the medical services provided.
An administrative law judge found that Surgical Specialties had the initial burden of proof regarding the reasonableness of its medical charges and that its evidence and testimony sustained the burden. The ALJ held that it was the insurer’s burden to establish that Surgical Specialties’ charges were unreasonable or unfair, but the carrier fell short.
The Labor and Industrial Relations Commission affirmed.
The Missouri Court of Appeals said that under state law, a worker or provider seeking payment has to prove that the fees and charges sought are “fair and reasonable.”
There is also a statutory prohibition against fees and charges that are “greater than the usual customary fee the provider receives for the same treatment or service when the payer for such treatment or service is a private individual or a private health insurance carrier,” the court said.
The court said Missouri case law has held that the burden “going forward with the evidence shifts to the employer or insurance carrier to prove that such medical bills were unreasonable and unfair.”
The ALJ “was simply recognizing that the evidence and testimony submitted by Surgical Specialties was sufficient to sustain its burden of production and to support the entry of judgment, should the evidence be deemed credible … such that it became the appellants’ obligation to assume the burden of coming forward with competing evidence,” the court said. “However, the burden of persuasion, and thus the ultimate burden of proof that its unpaid fees and charges were fair and reasonable, remained squarely on Surgical Specialties.”
The court further said the amendment to the Workers’ Compensation Law in 2005, requiring strict construction of its provisions, did not alter the evidentiary burdens borne by the parties in medical bill payment disputes.
The court also said there was sufficient evidence to support the commission’s final award ordering the insurer to pay Surgical Specialties the outstanding medical fees and charges, given the evidence that 99% of its services are provided to workers compensation claimants and that it consistently bills $19,763 for the same procedure.
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