Jerome Zerrer v. Ahal Concrete Contractors

Healthcare Provider: Timberlake Surgery Center

Employer: Ahal Concrete Contractors

Insurer: Amerisure Mutual Insurance Company

Employee: Jerome Zerrer

Hearing Date: July 18, 2017

Injury No.: 07-118635

MFD No.: 07-01488

Before the

Division of Workers'

Compensation

Department of Labor and Industrial

Relations of Missouri

Jefferson City, Missouri

Checked by: JKO

On July 18, 2017, a Medical Fee Dispute evidentiary hearing was held at the Division of Workers' Compensation in St. Louis regarding the Application For Payment of Additional Reimbursement of Medical Fees filed by the Healthcare Provider, Timberlake Surgery Center. The Healthcare Provider, Timberlake Surgery Center, was represented at the hearing by its attorneys, Mr. Jack B. Spooner and Mr. Christopher M. Johnson. Employer, Ahal Concrete Contractors, and its insurer, Amerisure Mutual Insurance Company, were represented at the hearing by their attorney, Mr. Andrew J. Sheehan. At the time of the hearing, the parties agreed on certain stipulated facts and identified the issues in dispute. These stipulations and the disputed issues, together with the findings of fact and rulings of law, are set forth below as follows:

1) The date of service for the medical care in this Medical Fee Dispute is November 12, $2014^{2}$.

2) Timberlake Surgery Center (Healthcare Provider) served a copy of the Application for Payment of Additional Reimbursement of Medical Fees by certified mail, return receipt requested, and complied with 8 CSR 50-2.030(1)(C).

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[^0]: ${ }^{1}$ The parties at hearing admitted into evidence Healthcare Provider Exhibit 6, which contained factual stipulations, as well as agreements on the admissibility of the various Exhibits offered into evidence in this case. So as not to be repetitious, the contents of the document were fully admitted into evidence and are a part of the record of the hearing, but only the factual stipulations will be repeated here, as the Exhibits admitted into evidence are already enumerated in a separate section of the Award.

${ }^{2}$ Although the parties submitted the written stipulations into evidence confirming their agreement that the date of service for the medical care is November 12, 2014, every other piece of evidence in the record, including Healthcare Provider's own medical records, billing statements, and Medical Fee Dispute Application, as well as Employer/Insurer's documents and filings, all agree that the date of service at issue is November 21, 2014. That being the case, I find that the submitted written stipulation has a typographical error in that (transposing the numbers in the date) which is hereby corrected in this Award, and that the intent of the parties was to actually stipulate that the date of service for the medical care is November 21, 2014.

3) The Application for Payment of Additional Reimbursement of Medical Fees was accepted with the Division on or about August 31, 2016.

4) The CPT Code in this Medical Fee Dispute for the medical services provided of 26545 is associated with treatment to the thumb.

5) Should the Division determine the Application for Payment of Additional Reimbursement of Medical Fees in accordance with Healthcare Provider group Exhibits 1 and 2 was timely filed and/or compensable for the purposes of this Medical Fee Dispute, $\ 5,760.57 would be the fair and reasonable fee for the medical services provided in this Medical Fee Dispute.

1) Is Healthcare Provider entitled to collect an additional $\ 3,801.34 in medical fees from Employer/Insurer on account of its Application for Payment of Additional Reimbursement of Medical Fees?

2) Is Employer/Insurer (Ahal/Amerisure) entitled to collect attorney's fees and costs under Mo. Rev. Stat. § 287.560 (2005) and Mo. Rev. Stat. § 287.040.3 (2005)?

The following exhibits were admitted into evidence:

1. Medical billing records of Timberlake Surgery Center and Explanations of Review (EOR) from Equian on behalf of Plocher Construction
2. Missouri Division of Workers' Compensation records and filings from Healthcare Provider in connection with this Medical Fee Dispute
3. Healthcare Provider's Response and Memorandum in Opposition to Employer/Insurer's Request for Award on Undisputed Facts
4. Affidavit in Support of Medical Fee Dispute
5. Medical treatment record of Dr. David M. Brown
6. Stipulation of Facts

A. Request for Award on Undisputed Facts filed February 21, 2017

B. Explanation of Review (EOR) from Equian dated January 15, 2015

C. Operative report of Timberlake Surgery Center for surgery on November 21, 2014

D. Motion to Dismiss

E. Motion for Costs Against Timberlake Surgery Center Pursuant to § 287.560 and $\S 287.040 .3$

F. Affidavit in Support of Employer/Insurer's Opposition of Medical Fee Dispute

Notes: 1) Any stray markings or writing on the Exhibits in evidence in this case were present on those Exhibits when they were admitted into evidence on July 18, 2017. No additional markings have been made since their admission on that date.

2) The parties asked that I take judicial and/or administrative notice of the file contents of the Division of Workers' Compensation file in this matter. Without objection, I will take such judicial and/or administrative notice of the file contents of the Missouri Division of Workers' Compensation file in this matter, and will review those contents in reaching my conclusions on the disputed issues in this case.

Based on a comprehensive review of the evidence, including the affidavits of the parties, the medical treatment records, the other documentary evidence, and the various motions and responses admitted into the record at hearing, I find:

1) Jerome Zerrer (Employee) received medical treatment, which is the subject of this Medical Fee Dispute, at Timberlake Surgery Center (Healthcare Provider) on November 21, 2014. According to the Operative Report (Exhibit C), he received surgery (left thumb UCL ligament reconstruction) performed by Dr. Brown on that date, on account of "sustaining a traumatic injury to his left thumb resulting in an ulnar collateral ligament tear..."

2) The medical bill from Timberlake Surgery Center (Exhibit 1) documents total charges for Employee's treatment on November 21, 2014 of \$7,200.71. On the face of the billing statement, it lists Plocher Construction as the Payer Name and the Employer Name. Additionally, in the Remarks section, it lists Plocher Construction with an address of 2808 Thole Plocher Road, Highland, IL 62249.

3) Following submission of their medical bill for the November 21, 2014 services, Healthcare Provider received an Explanation of Reimbursement (EOR) from Equian (Exhibits 1 and B) dated January 15, 2015. On the face of the EOR at the very top is "Plocher Construction." The EOR indicates that the submitted charges were reviewed and a payment of $\ 1,959.23 was determined to be the fair and reasonable amount owed for the medical treatment in question.

4) Healthcare Provider did not agree with the payment submitted with the EOR and filed an appeal letter dated January 28, 2015 (Exhibit 1) seeking additional reimbursement. Equian responded with a Re-Evaluation of the EOR dated March 18, 2015 (Exhibit 1), which, again, had "Plocher Construction" at the top and concluded that no additional reimbursement was appropriate in this case.