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All Contested Case Subject
Reimbursement Disputes
In General
Radiological services are properly paid applying a cost/charge ratio because a radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29).
Loose, Jacob R*, 13 CCHR 172 (2008) |
Martsfield, Brian P*, 13 CCHR 178 (2008) |
Braatz, Richard J*, 13 CCHR 112 (2008) |
Davis, James B.*, 13 CCHR 130 (2008) |
Downing, Brian T*, 13 CCHR 136 (2008) |
Franke, Shiree*, 13 CCHR 142 (2008) |
Harris, Kenneth R*, 13 CCHR 148 (2008) |
Hartman, Robert N*, 13 CCHR 154 (2008) |
Hernandez, Fermin*, 13 CCHR 160 (2008) |
McCann, Jack D*, 13 CCHR 184 (2008) |
Moss, Deborah L*, 13 CCHR 195 (2008) |
O'Neal, Dan R*, 13 CCHR 202 (2008) |
Penland, Kirk A*, 13 CCHR 208 (2008) |
Perkins, Craig E*, 13 CCHR 214 (2008) |
Schafer, Raymond E*, 13 CCHR 220 (2008) |
Kelso, Larry W*, 13 CCHR 166 (2008) |
Cox, Jonathan A. *, 13 CCHR 124 (2008) |
Coen, Ruthanne*, 13 CCHR 118 (2008) |
Nocita, Sebastian J.*, 13 CCHR 196 (2008) |
Aveleigra, Jose A.*, 13 CCHR 106 (2008) |
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts.
Braatz, Richard J, 13 CCHR 308 (2008) |
Coen, Ruthanne, 13 CCHR 318 (2008) |
Cox, Jonathan A, 13 CCHR 328 (2008) |
Downing, Brian T, 13 CCHR 348 (2008) |
Franke, Shiree, 13 CCHR 358 (2008) |
Harris, Kenneth R, 13 CCHR 368 (2008) |
Hartman, Robert N, 13 CCHR 378 (2008) |
Hernandez, Fermin H, 13 CCHR 388 (2008) |
Loose, Jacob R, 13 CCHR 408 (2008) |
Kelso, Larry W, 13 CCHR 398 (2008) |
Martsfield, Brian P, 13 CCHR 418 (2008) |
McCann, Jack D, 13 CCHR 428 (2008) |
Moss, Deborah l, 13 CCHR 438 (2008) |
Oneal, Dan R, 13 CCHR 458 (2008) |
Penland, Kirk A, 13 CCHR 468 (2008) |
Schafer, Raymond E, 13 CCHR 488 (2008) |
Davis, James B., 13 CCHR 338 (2008) |
Nocita, Sebastian J., 13 CCHR 448 (2008) |
Perkins, Craig E., 13 CCHR 478 (2008) |
Aveleigra, Jose A, 13 CCHR 298 (2008) |
An employer that has made an overpayment is entitled to an offset against future compensation under ORS 656.268. Kilby, Constance,
17 CCHR 7 (2012).
Reimbursement for expenses to attend a medical arbiter exam is not "compensation" against which a self-insured employer can make an offset for an overpayment under ORS 656.268. Kilby, Constance,
17 CCHR 7 (2012).
Reimbursement for expenses to attend a medical arbiter exam is not compensation under ORS 656.005(8) because it is not paid to a worker for the compensable injury or to ameliorate the effect of the compensable injury. Kilby, Constance,
17 CCHR 7 (2012).
Under ORS 656.268(13) an insurer could not offset an overpayment against the worker's reimbursement request for expenses related to travel to a medical arbiter exam because that reimbursement is not "compensation" under ORS 656.005(8). Kilby, Constance L.*,
16 CCHR 361 (2011).
Reimbursement for the cost of travel to a medical arbiter exam is not "compensation" under ORS 656.005(8) because such an exam is not a medical service and does not provide medical treatment since the exam's purpose is to evaluate impairment. Kilby, Constance L.*,
16 CCHR 361 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Laurelhurst Physical Therapy*,
16 CCHR 243 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Erhardt Physical Therapy*,
16 CCHR 229 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Chehalem Physical Therapy*,
16 CCHR 222 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Impact Physical Therapy*,
16 CCHR 236 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Therapeutic Associates, Inc.*,
16 CCHR 250 (2011).
A medical provider did submit a bill timely, although it delayed submission of the bill, where a private insurer had previously paid bills for treatment of the same injury and the provider timely submitted the bill within 60 days after it received notice of the workers' compensation claim. Fry, Robert S.,
16 CCHR 181 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Jackson County Physical Therapy*,
16 CCHR 135 (2011).
Fee discount contracts between medical providers and insurers can be enforced under the permanent version of OAR 436-009-0040 that preceded the temporary version of that rule in effect in 2008. Jackson County Physical Therapy*,
16 CCHR 135 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Capitol Physical and Hand Therapy*,
16 CCHR 145 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Chehalem Physical Therapy*,
16 CCHR 100 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Cascade Physical Therapy*,
16 CCHR 114 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Laurelhurst Physical Therapy*,
16 CCHR 153 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Laurelhurst Physical Therapy*,
16 CCHR 107 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Erhardt Physical Therapy*,
16 CCHR 128 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Therapeutic Associates, Inc.*,
16 CCHR 121 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. ProActive Orthopedic of Oregon City*,
16 CCHR 161 (2011).
Fee discount contracts betweeen medical providers and insurers are enforceable under the permanent version of OAR 436-009-0040 that preceded the temporary version in effect in 2008. Impact Physical Therapy*,
16 CCHR 93 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. ProActive Orthopedic of Gresham*,
16 CCHR 169 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Hood River Physical Therapy*,
16 CCHR 56 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Zomerschoe Physical Therapy*,
16 CCHR 77 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Clackamas Physical Therapy Associates*,
16 CCHR 49 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Canby Physical Therapy*,
16 CCHR 63 (2011).
Under former, temporary, OAR 436-009-0040(1), where the insurer and medical providers were both parties to a contract authorizing discounted payments by the insurer to the provider, the discounts the insurer applied to the providers' bills were proper. Back in Action Physical Therapy*,
16 CCHR 28 (2011).
Former, temporary OAR 436-009-0040(1) could properly be retroactively applied to allow discounted payment of medical provider bills under fee discount contracts where the rule's language expressly demonstrated the intent for the rule to be retroactive and where the medical providers' pre-existing rights were not prejudicially affected. Back in Action Physical Therapy*,
16 CCHR 28 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Tim Foley Physical Therapy*,
16 CCHR 42 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Umpqua Valley Physical Therapy,
16 CCHR 70 (2011).
Under OAR 436-009-0010(5), an insurer may not discount payment to a medical provider because the bill was submitted more than 60 days after the service was provided if the provider did not know there was a responsible workers' compensation insurer, even if the worker's private health insurer knew of the compensation claim. Durbin, Anna M.,
16 CCHR 84 (2011).
Fee discount contracts between medical providers and and insurers can be enforced under former temporary OAR 436-009-0040. Keizer Physical Therapy*,
16 CCHR 35 (2011).
Under former, temporary, OAR 436-009-0040(1), where the insurer and medical providers were both parties to a contract authorizing discounted payments by the insurer to the provider, the discounts the insurer applied to the providers' bills were proper. Back in Action Physical Therapy*,
16 CCHR 16 (2011).
Former, temporary OAR 436-009-0040(1) could properly be retroactively applied to allow discounted payment of medical provider bills under fee discount contracts where the rule's language expressly demonstrated the intent for the rule to be retroactive and where the medical providers' pre-existing rights were not prejudicially affected. Back in Action Physical Therapy*,
16 CCHR 16 (2011).
Under OAR 436-009-0040, Insurers may not apply fee discounts to bills from medical providers where those discounts originate in a contract if the provider and insurer are not both parties to that contract. Chehelam Physical Therapy,
16 CCHR 10 (2011).
A claimant was entitled to reimbursement for the purchase of compression socks where there was evidence in the record the attending physician had authorized the use of the socks. Anderson, Toni L.*,
15 CCHR 281 (2010).
OAR 436-010-0220(2), requiring attending physician approval for services to be reimbursed, does not require advance or contemporaneous approval, but only that there is approval. Anderson, Toni L.*,
15 CCHR 281 (2010).
Where the director had previously found $60 was a reasonable fee for a single test, the provider was entitled to $60 for each test performed, even though the manufacturer of the test stated $19.72 was a reasonable charge for each test. Intractable Pain Center*,
15 CCHR 236 (2010).
Where a medical test could not be performed without the use of a specimen cup the provider was not entitled to additional reimbursement for the cost of the cup as an item that is "over and above" the cost of materials required for the test itself. Intractable Pain Center*,
15 CCHR 236 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Capitol Physical and Hand Therapy*,
15 CCHR 212 (2010).
The former, permanent version of OAR 436-009-0040, the preceded the 2008 temporary rule, did not authorize the use of fee discount contracts between medical providers and insurers. ProActive Orthopedic of Gresham*,
15 CCHR 291 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Proactive Orthopedic of Oregon City*,
15 CCHR 217 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Laurelhurst Physical Therapy*,
15 CCHR 204 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Clackamas Physical Therapy Associates*,
15 CCHR 208 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Jackson County Physical Therapy*,
15 CCHR 200 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Umpqua Valley Physical Therapy*,
15 CCHR 186 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Hood River Physical Therapy*,
15 CCHR 196 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Zomerschoe Physical Therapy*,
15 CCHR 169 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Canby Physical Therapy*,
15 CCHR 174 (2010).
WCD's denial of reimbursement from the reopened claims program for settlement proceeds from two CDAs for the failure to follow procedural requirements regarding "prior written approval" before CDAs approved by board affirmed, and WCD not estopped from denying reimbursement. Cutshall, Bruce T.*,
15 CCHR 190 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Tim Foley Physical Therapy*,
15 CCHR 178 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Keizer Physical Therapy*,
15 CCHR 182 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply to billings submitted prior to the rule's effective date, and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Cascade Physical Therapy*,
15 CCHR 160 (2010).
The director did not err in dismissing claimant's request for administrative review without prejudice on the basis the request was premature, where the record did not show that insurer had received proper requests for reimbursement for prescriptions and mileage, or proper bills for massage services. Granville, Alton R.,
15 CCHR 165 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Laurelhurst Physical Therapy*,
15 CCHR 142 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Erhardt Physical Therapy*,
15 CCHR 128 (2010).
In a medical fee dispute, the director's order finding the insurer not liable for various charges related to a drug screen protocol administered to the worker or for a rebilling fee was affirmed. Becker, Tim A.*,
15 CCHR 111 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Therapeutic Associates, Inc.*,
15 CCHR 118 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Chehalem Physical Therapy*,
15 CCHR 123 (2010).
Because retroactive application of temporary 436-009-0040 would violate statutory time limits on temporary rules, the rule did not apply in this case and there was no other provision allowing for the application of an additional discount to payment for compensable medical services. Impact Physical Therapy*,
15 CCHR 133 (2010).
Where a medical provider contracts with a third entity to accept discounts for certain patients, former OAR 436-009-0040(1) prohibited an insurer from applying the discounted rate to the medical provider. Chehalem Physical Therapy*,
15 CCHR 59 (2010).
Insurer was not entitled to reduce payments to a medical provider, where the insurer and the medical provider did not have a contract, and the services were rendered after the effective date of the rules, because the temporary amendments to OAR 436-009 did not apply to the medical fee dispute. Chehalem Physical Therapy*,
15 CCHR 59 (2010).
A medical provider was entitled to the lesser of either its usual charge or the fee schedule maximum under a prior version of OAR 436-009-0040, which did not allow for application of a discount to medical services, because a temporary amendment to the rule was inapplicable. Back In Action Physical Therapy*,
15 CCHR 52 (2010).
The insurer's refund entitlement was denied, where no refund request was made to the medical provider, per OAR 436-009-0008, but rather the refund was ordered by the director from the insurer's response to inquiries made regarding disputed charges. Petty, Jolene,
15 CCHR 3 (2010).
Without evidence of a special report, insurer is not liable for a special report fee, because, under OAR 436-009-0015, medical providers cannot charge separately for chart notes, work releases, progress notes, etc. Petty, Jolene,
15 CCHR 3 (2010).
Insurer was not liable for a rebilling fee because no rule authorizes a "rebilling fee," where a rebilling fee cannot be converted into a monthly charge, or is not the equivalent of a "reasonable monthly service charge." Petty, Jolene,
15 CCHR 3 (2010).
No rule authorizes a "rebilling fee," where a rebilling fee cannot be converted into a monthly charge, or is not the equivalent of a "reasonable monthly service charge." Black, June A.,
14 CCHR 200 (2009).
Without evidence of a special report, insurer is not liable for a special report fee, because a special report fee is not for the completion of routine forms. Black, June A.,
14 CCHR 200 (2009).
No rule authorizes a "rebilling fee," where a rebilling fee cannot be converted into a monthly charge, or is not the equivalent of a "reasonable monthly service charge." Decker, Carl A.,
14 CCHR 208 (2009).
Without evidence of a special report, insurer is not liable for a special report fee, because a special report fee is not for the completion of routine forms. Decker, Carl A.,
14 CCHR 208 (2009).
Claimant was not liable for a three dollar statement charge because no rule allows a charge for the issuance of a statement. Decker, Carl A.,
14 CCHR 208 (2009).
No rule authorizes a "rebilling fee," where a rebilling fee cannot be converted into a monthly charge, or is not the equivalent of a "reasonable monthly service charge." Howard, Philip G.,
14 CCHR 204 (2009).
Doctor's $7,200 fee for spending 8 hours writing a response to an IME report is held not reasonable because the response is more elaborate than necessary. Doud, Michael J.,
14 CCHR 40 (2009).
RT's approval of the insurer's denial of payment for a records review on the basis that the insurer had not requested the records review ignored OAR provisions that do allow for payment and therefore the matter is remanded. Gilbert, Timothy R.,
14 CCHR 24 (2009).
WCD did not err in denying reimbursement to the insurance company because no explicit statutory language provides that death benefits are payable under ORS 656.278 or that death benefits are reimbursable under the Reopened Claims Program. Smallwood, Brian C,
13 CCHR 237 (2008).
WCD's conclusion that a recliner chair is not reimbursable under OAR 436-010-0230(10) is supported by substantial evidence where neither the worker nor the doctor provided a report that specifically set forth why the worker required an item not usually considered necessary to the great majority of workers with similar impairments. Foster, Agnes K,
13 CCHR 88 (2008).
When claimant does not have a health benefit plan, insurer is not required to pay interim medical benefits. Blacknall, Reese,
13 CCHR 77 (2008).
Physical therapist shall not provide compensable services to injured workers except as allowed by a governing MCO or as authorized by the worker's attending physician, if they do, then the insurer is not liable for the services. Rockholt, Dianne,
13 CCHR 45 (2008).
When insurer pays all bills that were properly submitted before the Order on Review became final, the payments were timely. Smith, Howard D,
13 CCHR 13 (2008).
The Workers' Benefit Fund should reimburse insurer for the additional amounts that it paid to the surviving spouse because it was ordered to do so by both the ALJ and WCB. Smallwood, Brian C*,
12 CCHR 326 (2007).
Estoppel only protects a person who changes a position in reliance on another's act or representation and is applicable to matters before WCD. Mitchell, Corrinne I,
12 CCHR 293 (2007).
The director is unable to decide a dispute regarding fees for medical services on a noncompensable claim. Ard, Alisha M*,
12 CCHR 228 (2007).
An insurer has 30 days from the receipt of the reimbursement request to pay the undisputed portion and provide reasons for non payment or reduction in payment. Myers, Terry,
12 CCHR 193 (2007).
When payment for medical services is stayed under ORS 656.313, any interest due is not payable to the worker because the worker did not forbear from collecting the medical services payment. Lyon, Kevin M,
12 CCHR 172 (2007).
The ALJ found there was substantial evidence to support MRU's finding that there was no dispute to review because the individual orders listed the specific disputed medical service and prescriptions and the medical reviewer concluded that these services and prescriptions had either been paid or not received. Smith, Howard D*,
12 CCHR 133 (2007).
Reimbursement for palliative care is not required when there is nothing in the record other than billing to connect the treatment to the accepted injury. Yekel, Stuart C*,
12 CCHR 101 (2007).
There is nothing in the laws or rules of law that prohibit an insurer from reimbursing the pharmacy directly for claim-related expenses, especially when because of worker's indigent status the injured worker is unable to pay for the prescription and then request reimbursement for the insurer. Foster, Agnes K,
12 CCHR 115 (2007).
An insurer is required to reimburse a worker upon request for actual and reasonable costs paid for prescriptions related to a compensable condition. Rojo-Heredia, Hector,
12 CCHR 84 (2007).
ORS 656.313(1)(b) indicates that an insurer should pay any interest due on stayed payments for medical services to payees other than the worker. Lyon, Kevin M*,
12 CCHR 74 (2007).
The two year time limit in OAR 436-009-0025(3) does not apply to a claim requesting payment of a bill for in-home medical services. Dougarian, Thomas,
12 CCHR 60 (2007).
Equitable estoppel does not bar an insurer from denying reimbursement of massage services when no treatment plan is prepared as required. Gatch, Suzanne M*,
12 CCHR 4 (2007).
A worker is not liable for disputed massage services under OAR 436-009-0015(1) and none of the exceptions apply when the treatment is related to an accepted compensable injury and the accepted condition is not medically stationary at the time of the services. Gatch, Suzanne M*,
12 CCHR 4 (2007).
OAR 436-009-0025 provides a two year statute of limitations on reimbursement requests. Cavazos, Mark,
12 CCHR 1 (2007).
An insurer is required to provide notice to a worker that he is required to file reasonable documentation of actual expenses, however until being notified the worker is entitled to reimbursement at the per diem rate. Cavazos, Mark,
12 CCHR 1 (2007).
A nurse practitioner does not need to be "authorized" to write compensable prescriptions when the nurse practitioner is under the direction and control of a duly qualified attending physician. Rojo-Heredia, Hector*,
11 CCHR 294 (2006).
When a medical supply is used over and above those usually included within a procedure, that supply is reported and billed separately. Mott, Carolyn,
11 CCHR 284 (2006).
A surgical tray not always used during a procedure to repair a laceration is a medical supply used over and above that normally used during the repair covered by the CPT codes for that procedure. Mott, Carolyn,
11 CCHR 284 (2006).
The CPT provision dealing with medical supply billing provides that billing can be under the CPT code, 99070, or a specific supply code. A HCPCS code is specific supply code. Mott, Carolyn,
11 CCHR 284 (2006).
Under former OAR 436-009-0010(5), late billings may be discounted only if there is evidence that the medical provider had notice or knowledge of the responsible workers' compensation insurer or processing agent. Beatty, Todd B,
11 CCHR 269 (2006).
A medical provider shall bill their usual and customary fee charged to the public. The submission of a bill establishes a rebuttable presumption that the fee is usual and the director, employer, or claimant can submit additional evidence against that presumption. Dorcy, Tommy H,
11 CCHR 238 (2006).
An employer cannot be really upset when a medical provider's response is a long report and the claims examiner did not limit the time or length of the requested response. Dorcy, Tommy H,
11 CCHR 238 (2006).
If the medical provider has notice or knowledge of the responsible carrier, billings for treatment must be rendered within 60 days of treatment or the carrier is not liable for payment. Rendering requires presenting the bill to the actual workers' compensation insurer or processing agent, not other carriers. Willson, Jeffrey T,
11 CCHR 234 (2006).
ORS 656.325 does not specify the parameters for an examination of a worker. An exam and report are not excessive under the statute when the doctor performs an examination, reviews the information, and writes a comprehensive report. Boydston, Randy D,
11 CCHR 188 (2006).
When the claimant timely cancels an independent medical exam and ARU notifies the doctor's office of the cancellation, a doctor's lack of knowledge of the cancellation because of his own internal office communication problems does not justify reimbursement for a file review. Rogers, Claude B,
11 CCHR 199 (2006).
When the claimant timely cancels the exam and ARU notifies the doctor's office of the cancellation, a doctor's lack of knowledge of the cancellation because of his own internal office communication problems will not justify reimbursement for a file review. Rogers, Claude B*,
11 CCHR 156 (2006).
WCD error occurs when MRU accepts at face value that certain examinations were performed in compliance with CPT. Wensorski, John,
11 CCHR 115 (2006).
Insurers are only required to pay medical bills submitted in proper form by the physician according to OAR 436-009-0030, medical visits cannot be submitted as a reimbursement by the claimant as a claim-related service. Egan, Gerard,
10 CCHR 440 (2005).
Remanded for claimant's failure to present evidence to support the claim. Parr, Randall L.,
10 CCHR 326 (2005).
Home health services were not reimbursable because they were not preauthorized by the health care provider or precertified by the MCO and they were excessive. Gordon, Rocky L.,
9 CCHR 341 (2004).
Insurer is liable for fees that are reflected in the bill as the usual and customary fee by CPT codes and by credible testimony. Whitfield, Turner*,
9 CCHR 275 (2004).
Insurer is liable for fees that are reflected in the bill as the usual and customary fee by CPT codes and by credible testimony. Cushman, Valerie,
9 CCHR 278 (2004).
Medical services provided by a non-MCO provider by referral from a non-MCO attending physician after claimant was notified of enrollment in the MCO are not reimbursable. Day, Jesse C.,
9 CCHR 179 (2004).
Insurer is entitled to offset reimbursement requests against previously paid overpayment. Egan, Gerard,
9 CCHR 115 (2004).
Swim therapy was reimbursable under ORS 656.245. Graham, Willie J.*,
9 CCHR 59 (2004).
Failure to complete a treatment plan on time made claimant's physical therapy non-compensable. Herman, Adalbert,
9 CCHR 21 (2004).
Failure to notify the doctor regarding the claim closure did not make the treatment reimbursable. Crowe, John*,
9 CCHR 13 (2004).
Insurer is not liable for reimbursement to physician because the worker was medically stationary, and neither an aggravation claim nor a request for palliative care was filed. Truesdell, Kellie,
9 CCHR 9 (2004).
SAIF was not liable for a lumbar epidural steroid injection Senn, David M.,
9 CCHR 6 (2004).
Insurer is not liable to reimburse for lodging expenses that are not properly documented. Egan, Gerard,
8 CCHR 364 (2003).
Insurer not liable for a diagnostic L4-5 and L3-4 right nerve block because claimant failed to show that the compensable condition made the diagnostic test necessary. Wallace, William C.,
8 CCHR 212 (2003).
Insurer is not precluded from denying payment for home health care because claimant did not change his position in reliance on any representation. Burland, Theodore F.,
8 CCHR 186 (2003).
Insurer not liable for cost of medical report prepared at claimant's request in anticipation of litigation. Olson, Patricia Y.*,
8 CCHR 105 (2003).
Substantial evidence supports MRU's finding that insurer is liable to reimburse claimant for out-of-pocket prescription expenses. Massingale, Frank A.*,
8 CCHR 84 (2003).
Insurer liable for cost of medical report sent four months after insurer's request. Olson, Patricia Y.*,
8 CCHR 8 (2003).
The NC-Stat was not a surface EMG, and so it was reimbursable pursuant to OAR 436-009-0015. Humphrey, Terrell L.,
7 CCHR 397 (2002).
Physician was not reimbursed because he failed to submit a bill to the insurer within the required 90 day period. McCutcheon, Jack,
7 CCHR 338 (2002).
Past practice of paying non-registered nurse did not warrant insurer payments after she was discovered to be non-registered. Ross, Paul E.*,
7 CCHR 299 (2002).
Past practice of paying non-registered nurse did not warrant insurer payments after she was discovered to be non-registered. Huskey, Wayne D.,
7 CCHR 294 (2002).
Reimbursement requests for prescription expenses were untimely submitted, and not reimbursable. Lunceford, Nancy A.,
7 CCHR 281 (2002).
Insurer is not liable for a preoperative doctor visit, which was not part of the global surgical package. Delous, Michael V.,
7 CCHR 251 (2002).
The disputed doctor visit was a preoperative visit, and the insurer was not liable for additional compensation. Flores, Linda,
7 CCHR 247 (2002).
Gym membership was not a reimbursable medical service for claimant's condition. Graham, Willie*,
7 CCHR 223 (2002).
NC-stat device functions as a surface EMG device, and is not compensable. Humphrey, Terrell L.*,
7 CCHR 214 (2002).
Meals purchased during recovery period were reasonable costs that were reimbursable. Rowe, Lori A.*,
7 CCHR 193 (2002).
Insurer incorrectly denied reimbursement for medical services Baines, Sherry Y.,
7 CCHR 158 (2002).
A medical examination was deemed to be diagnostic of a non-accepted condition, and thus not reimbursable. Archer, Larry,
7 CCHR 118 (2002).
A DCS did not cover outstanding medical billings, which were reimbursable. Fisher, Dennis,
7 CCHR 123 (2002).
Claimant's enrollment in an MCO prevented reimbursement from a physician outside the MCO. Gilmore, Dianna L.,
7 CCHR 111 (2002).
A medical examination performed solely to evaluate claimant's eligibility for jury duty is not reimbursable. Winningham, John R.,
7 CCHR 109 (2002).
Calculation of the worker's weekly wage included 5 hours of overtime per week, which adjusted the wage from $450.52 to $598.98. Holmes, Steven,
7 CCHR 11 (2002).
Mileage
An administrative order concerning mileage reimbursement is reviewed under the substantial evidence standard. Knight, Gary S.,
16 CCHR 300 (2011).
Where the evidence was unrebutted that the claimant had corrected his statement about the mileage he drove and that this was the distance driven on previous occassions, substantial evidence supported the administrative order's findings the claimant was entitled to be reimbursed for the requested number of miles. Knight, Gary S.,
16 CCHR 300 (2011).
Where claimant had scheduled three appointments in the same day, claimant was entitled to actual mileage for each trip requested, because it was reasonable for claimant to return home between scheduled appointments. Hitt, David A.,
14 CCHR 184 (2009).
After claimant filed a reimbursement request more than two years after incurring mileage costs over a nine year span, the ALJ held that OAR 436-009-0025(3), which requires request for reimbursements to be submitted within two years, applies only prospectively. Clendenon, Daniel M,
13 CCHR 233 (2008).
A worker enrolled in an MCO cannot receive reimbursement for out-of-pocket expenses to attend a consultation by an MCO member that was referred by a non-MCO member attending physician. Wolfe, Cheryl A,
12 CCHR 28 (2007).
Claimant will not be reimbursed for mileage to attend an MRI if there are no records indicating that claimant attended the MRI on a particular date and at a particular location. Wolfe, Cheryl A,
12 CCHR 31 (2007).
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