James Noel v Mondelez International Inc.
Release Date: June 9, 2021
Venue:
Cast
Schaefer, ALJ
Spooner (for Timberlake)
Schaller, employer
Summary: Timbercreek filed a medical fee dispute against employer and asserted the surgery center was underpaid about $30,000 related to fees for a rotator cuff repair performed 7 years ago after the carrier authorized the services. The ALJ found the charges fair and reasonable and omissions in the application of the date the charges were disputed did not deprive the Division of jurisdiction. Commission rejects employer's defense that reasonableness of bills is based on what is customarily received according to 287.140.3 (fee the provider "receives") and not what is customarily billed.
Comments: Employer argued the provider normally discounted its services at 47% of billed charges and to charge the "full" price was unreasonable fee when it produced a charge of $338 a minute. Employer introduce evidence of 1300 bills for similar services received similar reductions based on 287.140.3 that recovery is not "greater than the usual and customary fee the provider receives...." It also notes the surgery center added 150% mark up on its supplies.
The provider indicates it did not reduce claimant's liability from full charges, that it required claimant to agree to unconditionally pay any balance as a condition of services, and that a customary reduction to other patients was irrelevant to the issue of claimant's liability. The Commission recognized the principal that employer can reduce liability with evidence that personal liability is extinguished if the provider allowed write offs and reductions for their own purpose
The provider reportedly "marked up" the cost of implants 150%, but the employer did not show that the mark-up was different from other provider. The employer offered no evidence that it was surprised by the bill or evidence of prior transactions with the center to address reasonableness of pricing.
The commission found no statutory authority to award interest in a medical fee dispute.
The Commission does not explain how it applies statutory interpretation rules to construe "receives" in 287.140.3 to mean "billed" for the purposes and relies upon Farmer-Cummings which is a pre-reform case which shifted the burden of proof in Missouri comp compared to tort recovery to start with the position that any billed amount is reasonable rather than the collected amount more accurate reflects reasonableness.
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