Did the Division err in accepting the MFD Application? What is the appropriate remedy now?
Commission regulation 8 CSR 50-2.030(1)(B) provides:
(B) In order to initiate a reasonableness dispute case, the health care provider must first submit a Request for Case Status Information on a division-approved form to the division prior to the filing of an application for payment of additional reimbursement of medical fees. The health care provider shall file with the division an original application for payment of additional reimbursement of medical fees. The application shall contain all the following information:
- The name, address, and telephone number of the health care provider;
- Name, address, and telephone number of the employer and insurer against whom the application is being filed;
- Name, address, and Social Security number of the employee for whom health care services were rendered, together with the date of injury and date the services were provided, for all disputes;
- The amount in dispute;
- The date the first notice of the dispute of the medical charge was received by the health care provider. Per section 287.140.4(2) RSMo, such notice shall be presumed to occur no later than five (5) business days after transmission by certified United States mail; and
- Any additional information the division deems necessary to resolve the dispute.
Commission regulations 8 CSR 50-2.030(1)(D) and (F) provide:
(D) The application shall be filed on a form prescribed by the division and shall contain the required information. If the application does not include all the information required by this rule or proof of service is not filed with the division, the application will be rejected and will be returned for the additional information.
(F) Upon receipt of the application, the division will assign a medical fee dispute number and confirm acceptance or rejection of the application to the health care provider.
In this matter, the HCP did not state an actual date for the "date the first notice of the dispute of the medical charge was received by the health care provider." Instead, the HCP listed "TBD." Employer/insurer argues that such answer was insufficient. In its brief, employer/insurer argues that the HCP should have used the October 20, 2014 date as the notice date.
However, it appears that employer/insurer never sent an express notice of dispute to the HCP. Instead, employer/insurer sent two payments, one on October 28, 2014 and the second on March 16, 2015. Copies of these checks/payments are not in the record. Neither is there any indication in the record that such payments indicated that they were to be payments in full of
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employer/insurer's debt to the HCP. The parties stipulated that the HCP made other demands for payment, but with no apparent response from employer/insurer.
Accordingly, we find that the HCP's answer of TBD was more accurate than an actual date. The administrative law judge noted that for the purposes of establishing the timeliness of the MFD Application pursuant to § 287.140.4 RSMo, either date of payment suffices; the Application was filed on September 3, 2015, within the statute of limitations based off of either payment date.
Even if the Division erred in accepting the Application without a proper date, there is no provision for the Commission to dismiss the entire matter on this basis. On the contrary, the remedy pursuant to the regulation is to return the Application "for the additional information." In its brief, employer/insurer asserts that the notice was the date of its first payment. Accordingly, we have the additional information that would remedy the alleged error in the Application. We deny employer/insurer's first point.
What is the Meaning of "Receives" in § 287.140.3 RSMo?
Employer/insurer's second, third, and sixth points revolve around the meaning of the word "receives" in the statute.
Section 287.140.3 RSMo, provides:
- All fees and charges under this chapter shall be fair and reasonable, shall be subject to regulation by the division or the commission, or the board of rehabilitation in rehabilitation cases. A health care provider shall not charge a fee for treatment and care which is governed by the provisions of this chapter greater than the usual and customary fee the provider receives for the same treatment or service when the payor for such treatment or service is a private individual or a private health insurance carrier. The division or the commission, or the board of rehabilitation in rehabilitation cases, shall also have jurisdiction to hear and determine all disputes as to such charges. A health care provider is bound by the determination upon the reasonableness of health care bills.
(Emphasis added).
Employer/insurer argues that the HCP usually and customarily "receives" or collects a lower amount for the same services after private insurers or private individuals negotiate the initially charged fee to that lower amount.
Employer/insurer further argues that the plain and unambiguous terms of § 287.140.3 RSMo, means that the HCP may not charge more for services "than the normal, ordinary, customary amount the HCP habitually has collected for the same services when the payor was a private individual or a private health insurance company." Employer/Insurer Brief, p. 25.
In support of its position, employer/insurer presented evidence allegedly from 1300 billings for the same services regarding other patients (without Medicare/Medicaid). The billing amounts are similar to those charged regarding employee, which amounted to $38,576.21. However, as alleged by employer/insurer, the amount collected from other patients for the same services averaged $9,792.23.
The administrative law judge disagreed with employer/insurer's argument and held that as long as the initial charge is the same across the board to all payors, then that initial charge constitutes "the usual and customary fee the provider receives for the same treatment or service[.]" We agree with the administrative law judge. We disagree that the word "r