Va. Int'l Terminals, LLC v. Neurosurgical Specialists, Inc.
| Decision Date | 06 April 2021 |
| Docket Number | Record No. 1077-20-1 |
| Court | Virginia Court of Appeals |
| Parties | VIRGINIA INTERNATIONAL TERMINALS, LLC AND ARCH INSURANCE COMPANY v. NEUROSURGICAL SPECIALISTS, INC. |
UNPUBLISHED
Present: Chief Judge Decker, Judges Beales and O'Brien
Argued by videoconference
FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION
F. Nash Bilisoly (W. Thomas Chappell; Daniel A. D. Salmon; Vandeventer Black LLP, on briefs), for appellants.
Philip J. Geib (Philip J. Geib, P.C., on brief), for appellee.
Virginia International Terminals, LLC, and Arch Insurance Company (jointly, the employer) appeal the Workers' Compensation Commission's award to the medical provider, Neurosurgical Specialists, Inc. The employer contends that the Commission erred by concluding that the medical provider established a prima facie case that the medical bills reflected the prevailing community rate. Alternatively, the employer argues that regardless, it rebutted that presumption. Last, it challenges the Commission's award of attorney's fees to the medical provider. For the reasons that follow, we affirm the Commission's decision, including the award of attorney's fees.
In 2016, Calvin Piland was injured while working for Virginia International Terminals. He was awarded workers' compensation medical benefits for the injuries. Neurosurgical Specialists provided the injured employee with various medical treatments. The employer paid some, but not all, of the charges.
The medical provider filed a claim with the Commission for unpaid medical fees for services rendered from November 2016 through March 2017.2 The employer defended the claim, in pertinent part, on the ground that the amounts billed did not reflect the prevailing community rate. The medical provider also sought an award of attorney's fees for the employer's allegedly unreasonable defense of its claim.
At the evidentiary hearing, Tracy Patrick, the billing and coding supervisor for the medical provider, testified. She explained that Neurosurgical Specialists fixed its prices for various procedures based on an external fee schedule.3 The practice entered its internal fee schedule into a billing program. To create an invoice, billing office personnel enter the medical procedure codes into the program, and the program automatically generates the correspondingcharges. Patrick made clear that the medical provider billed for various procedures in the same fashion regardless of the identity of the payor.
The employer entered into evidence a deposition of Dr. David Waters, president of Neurosurgical Specialists. He explained that carriers pay the medical provider based on the type of medical procedure and without any consideration of the charged amount. That amount paid is set by the carrier or by the contract with a particular insurance provider. Dr. Waters stated that the practice does not compare its charges to those of other practices, and he did not know if the medical provider's charges were "reasonable." He also did not know how the practice determines its fee schedule. During his deposition, Waters could not answer many of the questions about the office's billing practices.
The employer also introduced into evidence a compilation of amounts paid to Neurosurgical Specialists from March 9, 2016, to March 9, 2018, for the same procedures at issue in this case. It argued that the accounts receivable showed that the medical provider accepted payments of 25%-90% less than it charged for the services in the instant case and thus demonstrated that the amounts charged were not reasonable or limited to the prevailing community rate.
Following the hearing, the deputy commissioner allowed the parties to brief the issue of whether "payments received by a medical practice [were] evidence of the prevailing community rate." After reviewing the briefs, the deputy commissioner ultimately ruled in the medical provider's favor. The deputy commissioner concluded that the medical bills were prima facie evidence that the contested charges were reasonable. She further found that the employer did not sufficiently prove that the medical provider's charges exceeded the prevailing community rate. Finally, the deputy commissioner awarded the medical provider $1,000 in attorney's fees basedon her conclusion that the employer's reliance on the payments received by the medical provider was per se insufficient to establish that the charges exceeded the prevailing community rate.
The employer requested review by the Commission, which unanimously affirmed the decision of the deputy commissioner. The Commission concluded that the deputy commissioner "correctly held that the presumption of reasonableness was applicable to the medical provider in this case." It also agreed that the employer's attempt to rebut the presumption was an unreasonable defense and supported the award of attorney's fees to the medical provider.
The employer raises three assignments of error on appeal. First, it argues that the medical provider was not entitled to a presumption that the charges reflected the prevailing community rate. Second, the employer alternatively suggests that it rebutted that presumption. Third, it contends that the Commission erred by awarding the medical provider attorney's fees.
Under settled principles of appellate review, we consider the evidence in the light most favorable to Neurosurgical Specialists as the prevailing party before the Commission. See Newport News Shipbldg. & Dry Dock Co. v. Wardell Orthopaedics, P.C., 67 Va. App. 404, 412 (2017). "The Commission's determinations of fact are conclusive and binding on appeal . . . ." Carrington v. Aquatic Co., 297 Va. 520, 522 (2019); see also Code § 65.2-706(A). However, this Court is "bound by the [C]ommission's findings of fact" only if "'there was credible evidence presented such that a reasonable mind could conclude that the fact in issue was proved,' even if there is evidence in the record that would support a contrary finding." Anderson v. Anderson, 65 Va. App. 354, 361 (2015) (alteration in original) (quoting Artis v. Ottenberg's Bakers, Inc., 45 Va. App. 72, 83-84 (2005) (en banc)). Nevertheless, "[s]uch deference to the Commission does not extend to questions of law, which we review de novo." Id.
The employer contends that the Commission erred by determining that a medical provider's bill can constitute prima facie evidence that the charges were consistent with the prevailing community rate without evidence beyond the bill itself.
Under the Virginia Workers' Compensation Act, an employer must "furnish or cause to be furnished . . . necessary medical attention" to treat a compensable injury or illness "free of charge to the injured employee." Code § 65.2-603(A)(1).4 Under this statute, "if the [C]ommission enters an award for an injury resulting in an employee's work incapacity, the employer must pay for all reasonable and necessary medical treatment for the injury." Ceres Marine Terminals v. Armstrong, 59 Va. App. 694, 702-03 (2012). The charges for medical treatments for the compensable injury or illness "shall be subject to the approval and award of the Commission." Code § 65.2-714(A). In effect, the purpose of this statutory provision is to prevent medical providers from "overcharg[ing] for their services." Fredericksburg Orthopaedic Assocs. v. Fredericksburg Mach. & Steel, 62 Va. App. 83, 88 (2013) (quoting Bee Hive Mining Co. v. Indus. Comm'n, 144 Va. 240, 242 (1926)). At the time of the disputed services, an employer's liability for a provider's charges was "limited . . . to such charges as prevail in the same community for similar treatment when such treatment is paid for by the injured person."5 Code § 65.2-605 (2012 & Supp. 2016).
It is clear that the Commission may consider a "medical bill as prima facie evidence that the charges were consistent with the requirements of the Act." Ceres, 59 Va. App. at 703. In other words, the Commission can accept a medical bill as evidence that the included medical charges reflect rates that prevail in the same community and are not excessive. See id. See generally Bogle Dev. Co. v. Buie, 19 Va. App. 370, 375 (1994) (), rev'd on other grounds, 250 Va. 431 (1995). If the Commission accepts a bill as providing prima facie proof, the burden falls to the employer to "prov[e] that the medical fee was excessive." Ceres, 59 Va. App. at 703.
The law is equally clear that just as the Commission may accept a bill as prima facie evidence, it may also decline to consider it as such. Fredericksburg Orthopaedic, 62 Va. App. at 89. See generally Bethea v. Commonwealth, 297 Va. 730, 750 (2019) (). In any case, a decision of the Commission regarding whether a medical bill is prima facie evidence that a charged fee is reasonable is a factual finding. See Fredericksburg Orthopaedic, 62 Va. App. at 87; see also Bethea, 297 Va. at 750 (); cf. Walters v. Littleton, 223 Va. 446, 452 (1982) ().
The employer suggests that Fredericksburg Orthopaedic "clarified" the holding in Ceres and stands for the proposition that in order for the presumption to apply, the medical provider must present some evidence that its charges were limited to the prevailing community rate. In Fredericksburg Orthopaedic, 62 Va. App. at 85-86, the medical provider consistently used twodifferent fee...
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