En Banc Decision of the WCAB on Surgery Center Billing

The WCAB evaluated a case on surgery center billing charges.

The surgery center in this case filed a lien for $31,007. The lien went to trial because the defendant disputed the charges. The Workers’ Compensation Judge (WCJ) allowed the full amount of the lien. The WCJ indicated the defendant did not raise the reasonableness and necessity of treatment in the Stipulations and Issues framed at the trial.

The WCJ indicated in the opinion that even if the defendant would have raised the reasonableness issue, the defendant did not meet the burden of proving the lien was unreasonable. The defendant filed a petition for reconsideration which resulted in this en banc decision.

The WCAB referred to a previous en banc decision in Kunz v. Patterson Floor Covering. They also cited another case for the proposition that the burden of proof lies with party or lien claimant holding the affirmative on the issue. In this case, the surgery center. The WCAB indicated that the defendant does not have the burden to show that the surgery center bill was unreasonable.

The WCAB indicated they believed the WCJ misinterpreted their holding in Kunz.

It appears that the WCAB is stating that a surgery center bill has to be reasonable on its face. It wont be presumed reasonable as several in the industry had contended. It must be reasonable on its face even if the defendant doesn’t challenge it. In this case the defendant never even raised the reasonableness at trial level and it was still sent back to the WCJ for evaluation of the bills reasonableness. Therefore, even though there may have been no defense the defendant prevailed.

Case: Jimenez v. Galaxy Shade Systems
This is an en banc decision of the WCAB

Harvey Brown
3501 Jamboree Rd. Suite 602
Newport Beach, CA 92660

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