VICTORIA HEDGEPETH
v.
WAL-MART ASSOCIATES INC NATIONAL UNION FIRE INS CO OF PITTSBURG, Insurance Carrier
WALMART CLAIMS SERVICES, INC., Claim Administrator
Jurisdiction Claim No. VA00000265965
Virginia Workers Compensation
Virginia In The Workers’ Compensation Commission
March 19, 2021
Date
of Injury May 1, 2010
Claim
Administrator File No. C0478700
No
Appearance For the Claimant.
Philip
J. Geib, Esquire For the Medical Provider, Adult and
Pediatric Neurosurgery
Evan
G. Edwards, Esquire For the Defendant.
REVIEW
on the record by Commissioner Marshall, Commissioner Newman,
and Commissioner Rapaport at Richmond, Virginia.
ORDER
MARSHALL Commissioner
The
medical provider requests review of the Deputy
Commissioner’s September 8, 2020 Opinion denying its
application. We AFFIRM in part and VACATE in part.
I.
Material Proceedings
The
claimant suffered a compensable injury by accident on May 1,
2010. An October 5, 2010 Award Order granted temporary total
disability and medical benefits for a neck injury. A
September 4, 2015 Opinion awarded treatment for the
claimant’s right arm and shoulder due to radiating
symptoms causally related to her injury and subsequent
surgery.
The
medical provider filed September 2, 2018, September 10, 2019,
and March 30, 2020 applications seeking payment for services
rendered by Dr. Tina Rodrigue and a surgical assistant for
various dates of service from August 4, 2010 through April 3,
2014. The medical provider also sought an award of
attorney’s fees and costs pursuant to Virginia Code
§ 65.2-713.
The
parties resolved the claims for the surgical
assistant’s charges for all dates of service and the
claims for Dr. Rodrigue’s charges for all dates of
service other than April 3, 2014. Their agreement was
memorialized in a Stipulated Order entered by the Commission
on August 20, 2020. The only issues remaining for hearing
were the defendants’ responsibility for Dr.
Rodrigue’s services on April 3, 2014 and the medical
provider’s request for attorney’s fees. The
defendants disputed the application on the grounds that they
paid the medical provider according to the terms of a
contract and that they did not unreasonably defend the claim.
The
matter was scheduled for an on-the-record hearing. Both
parties submitted timely position statements and supporting
evidence. The Deputy Commissioner issued a September 8, 2020
Opinion. He found the medical provider’s submission of
the bills for the services of Dr. Rodrigue and the surgical
assistant were prima facie evidence of the reasonableness of
the charges. The medical provider argued that the defendants
failed to meet their burden to prove that the payments made
met the prevailing community rate. The Deputy Commissioner
rejected this argument, noting that it ignored holdings by
the Commission and the Court of Appeals of Virginia stating
that an insurance carrier could prove that contractual
agreements between it and the provider superseded the
provisions of Virginia Code § 65.2-605. He found the
defendants met their burden of proving the existence, terms,
and application of a contract that was in place at the time
the medical provider performed the services at issue.
Specifically, United Healthcare contracted with the medical
provider for the provision of services rendered under the
OneNet Preferred Provider Organization (PPO) health network,
which administered a workers’ compensation benefit
program in association with United Healthcare. The Deputy
Commissioner determined that the contract applied to both Dr.
Rodrigue and the surgical assistant. He found no evidence
supporting the medical provider’s assertion that it had
opted out of the contract.
The
Deputy Commissioner held that the Commission was the wrong
forum for the medical provider to pursue its claim that the
defendants failed to make payments in accord with the
contract. He concluded the parties were bound by the
agreement’s mechanism for resolving disputes between
them regarding payments, including the time limit imposed for
requesting resolution of any disputes. The contract contained
a provision requiring that the medical provider contest any
payment made “within a 12-month period following the
date the claim was paid.” The evidence established the
carrier paid for Dr. Rodrigue’s April 3, 2014 services
by May 2, 2014. The medical provider did not contest payment
until filing its September 2, 2018 application. Accordingly,
the Deputy Commissioner found the medical provider was barred
from seeking relief. The September 2, 2018, September 10,
2019 and March 30, 2020 applications were denied.
The
medical provider filed a timely request for review. Its
assignments of error are summarized as: (1) The Deputy
Commissioner erred in finding the contract applied to the
charges for the surgical assistant’s services; (2) The
Deputy Commissioner erred in finding the contract applied to
the charges for Dr. Rodrigue’s services; (3) The Deputy
Commissioner erred in determining the defendants were not
required to put on affirmative evidence of the means by which
they reduced/repriced the billed charges in accord with the
contract; and (4) The Deputy Commissioner erred in failing to
require the defendants to put on affirmative evidence of the
prevailing community rate.
II.
Findings of Fact and Rulings of Law
A.
Charges for Surgical Assistant’s Services
We
first address the medical provider’s contention that
the Deputy Commissioner erred in addressing the claim for the
surgical assistant’s charges. The...