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Clarity on Role of Non-Treating Provider in Worker's Compensation Matter (PA)

January 7, 2022

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<p style="text-align: justify;">On December 22, 2021 in the case captioned <em>Keystone Rx LLC v. Bureau of Workers' Compensation</em>, the Pennsylvania Supreme Court ruled that non-treating providers, such as pharmacies and imaging centers, may not have a role in the process of non-utilization review.</p>
<p style="text-align: justify;">This case arose when Claimant Thomas Shaw, an employee of the Roman Catholic Archdiocese of Philadelphia, was injured and subsequently prescribed medications by his physician. Keystone Rx LLC dispensed the drugs and billed the employer’s insurer, Compservices/AmeriHealth Casualty Services.</p>
<p style="text-align: justify;">The insurer filed a utilization review request. The utilization review organization determined that all medications dispensed after Nov. 2, 2016 were unreasonable and unnecessary because they were unrelated to Shaw’s workplace knee injury.</p>
<p style="text-align: justify;">The unanimous opinion says the Workers Compensation Act makes it clear that providers have no property interest in their claims until after utilization review determines the goods or service are reasonable and necessary. Therefore, the Court established that a non-treating provider, such as a pharmacy, does not need to be given either notice or an opportunity to defend in utilization review (UR) proceedings.</p>
<p style="text-align: justify;">The Pennsylvania Chamber of Business and Industry. Insurance Federation of Pennsylvania, American Property Casualty Insurance Association and the National Association of Mutual Insurance Companies were among groups that filed amicus briefs after Compservices appealed to the Supreme Court.</p>
Thanks to Alex DiMeo for his contribution to this post. Please contact <a href="">Heather Aquino</a> with any questions.


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