In Missouri workers’ compensation cases, there are two primary types of cases that may be brought against employers and their insurers. The first type of case is the primary workers’ compensation case, the “injury case,” where an injured worker seeks compensation for medical expenses, lost wages, and disability in connection with a work-related injury. These injury cases are brought by the injured worker against the employer/insurer. The second type of case is the medical fee dispute, which may be brought by health care providers who provided medical treatment to an injured worker. Medical fee disputes are brought by a health care provider seeking payment or additional reimbursement for their services from the employer/insurer. Many employers and insurers are unaware of the procedural requirements for medical fee disputes, ultimately leading to missed deadlines and other overlooked opportunities for defense.
There are four things every professional who handles workers’ compensation claims should keep in mind:
- Medical fee disputes are between the health care provider and the employer/insurer, not the injured worker.
- Medical fee disputes must be brought within the statute of limitations, which is different from the statute of limitations for workers’ compensation injury claims.
- Medical fee disputes may be initiated by a health care provider even if the underlying workers’ compensation case is resolved and the employer/insurer has closed their file.
- Failure of the employer/insurer to defend a medical fee dispute may result in a default judgment for the entire amount in dispute, plus interest and the attorney fees of the health care provider.
The medical fee dispute team at Andereck Evans has experience in defending employers and insurers in medical fee disputes at all levels.
Parties to a medical fee dispute.
There are two types of medical fee disputes which health care providers may initiate: a “direct pay” dispute and a “reasonableness” dispute. The “direct pay” dispute is initiated when a health care provider treated a patient for a work injury, but the employer/insurer has denied treatment. The denial could be due to the employer contesting whether the injured employee was involved in a work-related accident, whether the injury was from an accident (or another cause), or whether the treatment is/was necessary to cure and relieve the effects of a work-related injury. If the health care provider files a direct fee dispute, the medical fee dispute is joined with the underlying workers’ compensation injury case. If the employer/insurer is ordered to pay for the treatment, the judge may order that the employer/insurer pay the health care provider directly, instead of paying the medical fees to the injured worker, as is done in most cases. The second type of dispute, a “reasonableness” dispute, is initiated when the employer/insurer has authorized the medical treatment, but disputes that the charges are “reasonable.”
Regardless of whether the case is a direct pay dispute or a reasonableness dispute, § 287.140.4, RSMo. makes clear, “The employee shall not be a party to a dispute over medical charges, nor shall the employee’s recovery in any way be jeopardized because of such dispute.”
The statute of limitations for medical fee disputes
It is important for all parties to understand that there is a different statute of limitations for a medical fee dispute than there are for underlying workers’ compensation cases. In most workers’ compensation injury cases, an injured worker has two or three years to file a claim for compensation. § 287.430, RSMo. Depending on the type of case, the limitation period runs from the date of the accident, the date the last medical payment was made by the employer, or from the “date of diagnosis” in the case of an occupational injury. Cook v. Missouri Highway & Transp. Comm’n, 500 S.W.3d 917, 926 (Mo.App. S.D. 2016).
In contrast, medical fee disputes have a shorter statute of limitations period. If the date of service is before July 1, 2013, then the health care provider has two years from the date they receive a “notice of dispute.” § 287.140.4, RSMo. If the date of service is after July 1, 2013, the health care provider only has one year from the notice of dispute to initiate the case. Id. A notice of dispute must be in writing and explain the basis for the dispute. Id.
If the employer/insurer believes that a medical fee dispute has been initiated out of time, the employer/insurer may file a Request for Award on Undisputed Facts to ask that the case be dismissed. 8 C.S.R. 50-2.030(1)(P). After the employer/insurer files a Request for Award, the health care provider has an opportunity to file a response before the Administrative Law Judge (ALJ) rules on the Request. Id. If the ALJ determines that the case was not initiated within the statute of limitations, she may dismiss the case. Id. If the ALJ is not sure whether the case was initiated within the statute of limitations, the case will be set for a hearing for further evidence.
Medical fee disputes can be initiated even if the underlying workers’ compensation case is closed
After a workers’ compensation injury case is resolved, many times, the employer/insurer will pay out any compensation owed as a lump sum and close their files. However, a health care provider may still initiate a medical fee dispute if there were medical fees that were unpaid or not paid in full. The attorney who handled the workers’ compensation injury case may not receive a notice for a medical fee dispute. That is why it is important for adjusters and workers’ compensation professionals who receive notices from the Division of Workers’ Compensation to know how to respond when a medical fee dispute case is initiated to make sure they are adequately defended.
Failure to defend against a medical fee dispute may result in a default judgment
Employers/insurers have a variety of defenses against medial fee disputes. However, to bring those defenses, they must participate in the case! Too many medical fee dispute cases end with the health care provider getting default awards of the entire amount in dispute plus attorney fees and even interest because the employer/insurer failed to tender a defense against the case. Attorney fees may be awarded to health care provider if the employer/insurer “unreasonably” defends a case. § 287.560, RSMo. Many judges see a default at a hearing as an “unreasonable defense” and will order the employer/insurer to pay the attorney fees for the health care provider in the case of a default.
Conclusion
It is important for employer/insurers to be aware that medical fee dispute cases may be initiated even after the underlying injury case is resolved and may involve significant exposure. That is why it is important for adjusters and workers’ compensation professionals handling claims for either the employer or the insurer to handle notices of medical fee disputes diligently. Since medical fee disputes involve different regulations and procedures from underlying injury cases, it is important to choose a law firm with experience in defending medical fee disputes specifically. If you have questions about medical fee disputes, please contact one the experienced lawyers on our medical fee dispute team.
