Wilson, Matter of
| Decision Date | 16 February 1996 |
| Docket Number | Nos. 21385,21386,s. 21385 |
| Citation | 911 P.2d 754,128 Idaho 161 |
| Parties | In the Matter of David WILSON, Claimant. BOISE ORTHOPEDIC CLINIC, Provider-Respondent, v. IDAHO STATE INSURANCE FUND, Payor-Appellant. In the Matter of Frank FORD, Claimant. BOISE ORTHOPEDIC CLINIC, Provider-Respondent, v. IDAHO STATE INSURANCE FUND, Payor-Appellant. |
| Court | Idaho Supreme Court |
Evans, Keane, Boise, for Appellant.
These cases, which have been consolidated for the purposes of appeal, are appeals by the Idaho State Insurance Fund (SIF) from final decisions and orders of the Industrial Commission of the State of Idaho. In both cases, the Boise Orthopedic Clinic (BOC) billed the SIF for surgical assistant services performed on two claimants' work-related injuries. The SIF asserted that these amounts were above the reasonable amount for such services and denied payment for the amounts it determined unreasonable. In both instances, the Industrial Commission (Commission) either approved or partially approved the disputed amounts and ordered the SIF to pay the approved amounts.
The SIF appealed. We affirm.
Occasionally, a surgical procedure requires some skilled assistance but not necessarily that of another surgeon. In such a case either a registered nurse or a certified operating room technician will be used. These "non-physician surgical assists" (surgical assists) reduce operating time and the risk of surgical complications while optimizing the surgical treatment by assuring the availability of the appropriate implants and instruments.
BOC performed a surgical repair of Frank Ford's torn left rotator cuff. Since Ford's injury resulted from a work-related accident, BOC billed the SIF $2,173.50 for this procedure. This bill included a surgical assist charge of $283.50. BOC billed for its surgical assist at 15% of the underlying procedure.
The SIF determined that the underlying surgery exceeded the usual and customary charge by $127.00, and that the surgical assist exceeded the usual and customary charge by $107.20. The SIF issued a preliminary objection and paid BOC the undisputed portion of the bill ($1,939,30).
BOC filed a motion for approval of disputed medical charges with the Commission. BOC noted that the service was not frequently documented by BOC and thus sufficient documentation was not available to show that the charge was consistent with the amount charged to non-industrial patients. However, in support of its motion BOC submitted: a copy of the bill to the SIF; a copy of a bill issued to a non-industrial patient; and a copy of a payment received on behalf of an unidentified patient with handwritten Current Procedural Terminology (CPT) codes identifying different procedures.
The Commission noted that BOC submitted no evidence as to whether the charges would be allowed by a hospital or professional service corporation. However, finding that the surgical assist was exceptional, unusual, variable, rarely provided, or new, the Commission employed a standard whereby reasonableness is determined on all relevant evidence. As a result, it found that BOC's statement of consistent billing made in its demand for payment letter "permit[ted] the inference that the disputed charges" were BOC's usual charges. The Commission entered an administrative order finding that the surgical charge did not exceed the usual and customary charge. The Commission also found that although the surgical assist did not exceed BOC's usual charge, the amount did exceed the maximum customary charge allowed ($257.00) based on the Commission's compilation of charges. (A subsequent amendment enlarged the data base from October 1992-March 1993 to July 1992-March 1993.) Payment for the surgical assist was ordered in the amount which did not exceed the maximum customary charge.
The SIF filed a motion for reconsideration and a motion to present additional evidence. It renewed its position that BOC did not submit sufficient, competent evidence to support its contention that the charges were "usual and customary." It also requested limited discovery of BOC and other providers as to their "usual charges" for two reasons. First, such information was not available to the SIF. Second, such information was needed for proper consideration of "all relevant evidence" as to the reasonableness of the disputed charges.
The Commission denied the SIF's motion to present additional evidence because it viewed the motion as an attempt to establish the Relative Value Schedule (RVS) as the basis for determining whether the SIF's reimbursement rate was reasonable. The Commission noted that the proper focus was upon the reasonableness of the provider's charge, not the reasonableness of the payor's reimbursement. The Commission granted the motion to reconsider, but after a de novo review upheld the administrative decision and ordered payment. The SIF appealed.
BOC performed an arthroscopic decompression of the subacromial space with a partial ostectomy on David Wilson's shoulder and a fasciotomy with a partial ostectomy on his elbow. Since Wilson's injury resulted from a work-related accident, BOC billed the SIF $3,121.38. Included in this bill was a charge for a surgical assist on the shoulder surgery ($301.88) and a similar charge for the elbow surgery ($107.00). These charges were based on 15% of the underlying procedure.
The SIF determined that the amounts charged for the surgical assists exceeded the usual and customary charge by $100.63 for the shoulder surgery and $37.00 for the elbow surgery. BOC received an explanation of benefits and was paid the undisputed portion of its bill ($2,983.75).
BOC filed a motion for approval of disputed medical charges with the Commission. In support of its motion, BOC submitted: its bill with the disputed charge; a copy of an explanation of benefits from an unnamed payor containing handwritten CPT codes; and a copy of an explanation of benefits from Idaho Power with a handwritten CPT entry.
The Commission noted that BOC submitted no evidence that a hospital or professional service corporation would allow the charges. However, the Commission found that BOC's demand for payment letter permitted the inference that the disputed charges were its usual charges. As a result, the documentation provided and the Commission's compilation of charges from October 1992 to March 1993 supported the conclusion that the disputed charges were reasonable. (Again, a subsequent amendment enlarged the range to July 1992--March 1993.)
The SIF filed a motion to reconsider and a motion to present additional evidence. The Commission denied both motions. Since the Commission had not adopted RVS or a standard which focused on the reasonableness of the reimbursement rate, it felt evidence of such standards was irrelevant. The Commission focused on the reasonableness of BOC's charges and found they were supported by sufficient evidence. The SIF appealed.
These two cases were consolidated for the purpose of appeal. After the SIF filed its notice of appeal, BOC sought and received a waiver from further participation in these proceedings.
1. Whether the Commission erred when it considered the evidence submitted by BOC.
2. Whether the Commission erred in rejecting the SIF's attempt to use the RVS as a standard for determining reasonableness.
3. Whether the Commission's determinations as to the disputed charges are supported by substantial, competent evidence.
4. Whether the dispute resolution mechanism provided by the Commission's Judicial Rule violates state and federal constitutional due process, the rules of equity, or I.C. § 72-712.
Supreme Court review of Industrial Commission decisions is limited to a determination whether the findings of fact are supported by substantial and competent evidence. I.C. § 72-732(1); Davaz v. Priest River Glass Co., 125 Idaho 333, 336, 870 P.2d 1292, 1295 (1994); Snyder v. Burl C. Lange, Inc., 109 Idaho 167, 169, 706 P.2d 56, 58 (1985). Substantial evidence is more than a scintilla of proof, but less than a preponderance. In short, it is relevant evidence which a reasonable mind might accept to support a conclusion. Kinney v. Tupperware Co., 117 Idaho 765, 769, 792 P.2d 330, 334 (1990).
The Industrial Commission is empowered to approve all claims for medical and related services. I.C. § 72-803. Pursuant to its rule-making authority, the Commission adopted a set of criteria for the approval of all disputed medical charges. IDAPA 17.02.0831.
According to this criteria, an acceptable charge for medical services is one which is the "[p]rovider's reasonable charge for Medical Services furnished to industrially injured patients." IDAPA 17.02.08031.01. Reasonableness can be determined upon proof that the charge does not exceed the provider's "usual" charge nor exceeds the "customary" charge. IDAPA 17.02.08031.02(d). The "usual" charge is "the most frequent charge made by an individual Provider for a given service to non-industrially injured patients." IDAPA 17.02.08031.02(h). The "customary" charge is a charge which is within the range established by the Commission, but no lower than the 85th percentile and no higher than the 90th percentile of usual charges made by Idaho providers for a given service. IDAPA 17.02.08031.02(i). A charge may also be deemed reasonable if it does not exceed the total charge allowed for a given service by a duly authorized hospital or professional service corporation. IDAPA 17.02.08031.02(d). However, if a charge is "exceptional, unusual, variable,...
To continue reading
Request your trial
-
Aberdeen-Springfield Canal v. Peiper
...particular situation.'" City of Boise v. Industrial Comm'n, 129 Idaho 906, 910, 935 P.2d 169, 173 (1997) (quoting In re Wilson, 128 Idaho 161, 167, 911 P.2d 754, 760 (1996)). The collection of ASCC assessments is enforced by the filing of a lien against the property of the delinquent shareh......
-
Bradbury v. Idaho Judicial Council, 26361.
...132 Idaho 397, 973 P.2d 749 (1999); City of Boise v. Industrial Comm'n, 129 Idaho 906, 935 P.2d 169 (1997); and Matter of Wilson, 128 Idaho 161, 167, 911 P.2d 754, 760 (1996). To determine whether an individual's due process rights under the Fourteenth Amendment have been violated, courts m......
-
Miller v. Ririe Joint School Dist. No. 252
...of the board in favor of the attorneys who represented them in a prior proceeding." The district court quoted In the Matter of Wilson, 128 Idaho 161, 167, 911 P.2d 754, 760 (1996), for the proposition that "due process is not a concept rigidly applied to every adversarial confrontation, but......
-
Oxley v. Medicine Rock Specialties, Inc.
...(citing Laundry v. Franciscan Health Care Ctr., 125 Idaho 279, 282, 869 P.2d 1374, 1377 (1994)); Boise Orthopedic Clinic v. Idaho State Ins. Fund, 128 Idaho 161, 164, 911 P.2d 754, 757 (1996). The Commission's conclusions regarding the credibility and weight of evidence will not be disturbe......