Special Workers' Compensation Alert - Pennsylvania

Pennsylvania Supreme Court Agrees To Hear Appeal on Issue of Due Process for Providers in UR Proceedings That Are Not Healthcare Providers as Defined in the Act

The Pennsylvania Supreme Court recently granted a request to hear appeals of the Commonwealth Court’s decision in Keystone RX, LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office (Compservices, Inc./Amerihealth Casualty Services), 1369 C.D. 2018; filed December 12, 2019; by Senior Judge Leadbetter, where the Commonwealth Court held that, for future Utilization Review (UR) request filings, a provider that is not a defined healthcare provider under the Act must be afforded notice and given an opportunity to intervene. The court found that there are due process issues for providers, such as the pharmacy in this case, because they are precluded from participating in the UR process and the results can follow them to the Fee Review process, to their detriment.

In Keystone, a prior UR Determination was used in a subsequent Fee Review hearing as the basis to obtain a dismissal of the pharmacy’s Application for Fee Review. The UR Determination had found treatment not reasonable and necessary; it was challenged by a petition and later disposed of by a Compromise and Release Agreement.

The appellants (the employer and Bureau of Workers’ Compensation Fee Review Hearing Office) maintain that the Commonwealth Court erred in three ways; that the court:

(1) improperly assumed the role of the legislature by imposing a new rule that gives non-healthcare providers standing in the UR process; (2) wrongly gave non-healthcare providers the right to void, at any time, a UR Determination that found the treatment of the physician who prescribed the services of the non-healthcare provider to be not reasonable and necessary; and (3) violated the separation of powers doctrine by imposing a new requirement onto the process for conducting utilization review of a treating healthcare provider by directing non-treating entities be given notice and an opportunity to intervene.

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