Workers’ Comp In-Cites
Welcome to the latest edition of Schaff & Young's Workers' Comp In-Cites. Designed to provide our clients with practical insight, Workers' Comp In-Cites outlines recent developments in Pennsylvania workers' compensation law and explains how those decisions impact our clients and their cases. Barbara Young, Michael Schaff and the other attorneys at Schaff & Young, P.C. are always available to discuss these cases – or any other questions or concerns you might have. Just give us a call at (215) 988-0090 or send an email to We look forward to hearing from you.

Commonwealth Court Tackles Medical Bill Payment & Downcoding Procedures

With two decisions in April, the Commonwealth Court has addressed a number of issues and concerns related to downcoding, i.e., the ability of an insurer to change the billing and procedure codes for medical care. In Walsh v. Bureau of Workers' Compensation Fee Review Hearing Office (Traveler's Insurance Co.), the Commonwealth Court ruled that before downcoding a provider's claim for payment for medical services under the Workers' Compensation Act, an insurer must comply with the procedures set forth in 34 Pa. Code § 127.207. If an insurer fails to comply with these procedures, the Bureau must resolve the matter in favor of the provider.

In addition, in Witkin v. Bureau of Workers' Compensation Fee Review Hearing Office (State Workers' Insurance Fund), the Commonwealth Court ruled that a provider's fee review application is not be barred based upon a prior decision involving the same parties if the hearing officer did not conduct a hearing or address whether the insurer complied with Section 127.207 of the Regulations. Thus, under section 306(f.1)(1)(i) of the Act, a court or administrative agency may not rely upon a prior determination of a CPT code and must instead hold a hearing to determine whether the insurer strictly complied with the Regulations and whether the proper CPT code was used.

May 2013 Edition
Volume VII
Number 4

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