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Supreme Court of Pennsylvania Justices Highlight Failings of Peer-Review Structure

Posted On behalf of Schmidt Kramer on Jan 05, 2016 in General

peer-review processOn Dec. 21, the Supreme Court of Pennsylvania reversed a Superior Court decision that awarded attorney fees to Doctor’s Choice Physical Medicine & Rehabilitation Center.

The court ruled that submitting a healthcare provider’s invoices to a peer-review organization is sufficient enough for an insurance carrier to dispute a treatment as unnecessary and thus deny reimbursement under the Motor Vehicle Financial Responsibility Law.

The Supreme Court of Pennsylvania’s decision focused on the shortcomings of the peer-review process. Local attorneys believe the peer-review issue will not change unless the legislature dedicates attention to the process.

Schmidt Kramer partner Scott Cooper filed an amicus brief, which is a document filed by those not involved in the case, but who have a strong interest in it, on behalf of the Pennsylvania Association for Justice. He notes that the peer-review process has a lot of problems, but likely won’t be changing anytime soon.

The case in question stemmed after an accident wherein the victim’s healthcare provider, Doctor’s Choice, submitted invoices for the victim’s care to her insurance carrier, Travelers Personal Insurance Co. Travelers requested peer review through IMX Medical Management Services, who then enlisted Dr. Mark Cavallo to conduct the peer review. Dr. Cavallo determined that the treatments were unnecessary. Doctor’s Choice argued that the treatments were reasonable and necessary and that the doctor’s review did not correspond with the Motor Vehicle Financial Responsibility Law.

The Motor Vehicle Financial Responsibility Law permits awarding attorney fees only if a court determines treatment was necessary. However, this only applies when the insurer has not challenged the necessity of treatment before a peer-review organization.

Ultimately, both parties continued to argue about fee awards and whether treatment was necessary until the case was brought in front of the Supreme Court of Pennsylvania for a resolution.