ADJ11637452 — California WCAB decision

What the panel ordered

Petition for Reconsideration denied.

Lien claimant Riverside Community Hospital seeks reconsideration of the December 2, 2022 Findings and Order disallowing lien reimbursement in excess of amount previously paid.

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What was disputed, and how it came out

Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.

LiensDefendant prevailedmultiple body parts

From the decision · page 1Lien claimant, Riverside Community Hospital, seeks reconsideration of the December 2, 2022, Findings and Order. The workers' compensation administrative law judge (WCJ) found that lien claimant did not show that it was entitled to reimbursement in excess of the amount paid by the defendant previously. Accordingly, the WCJ ordered that the lien be disallowed, and that lien claimant take nothing.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Favours Defendant prevailed

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code

Labor Code section 4660(a)

Employer liable for reasonable expense of treatment.

From the decision · page 2Pursuant to Labor Code section 4660(a), "the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment." The OMFS "shall establish reasonable maximum fees." (Lab. Code, § 5307.1.) The OMFS was promulgated by the Administrative Director (AD) pursuant to the authority granted by the Legislature in Sections 133, 4603.5, 5307.1 and 5307.3.

Labor Code

Labor Code section 5307.1

OMFS establishes reasonable maximum fees for medical treatment.

From the decision · page 2Pursuant to Labor Code section 4660(a), "the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment." The OMFS "shall establish reasonable maximum fees." (Lab. Code, § 5307.1.) The OMFS was promulgated by the Administrative Director (AD) pursuant to the authority granted by the Legislature in Sections 133, 4603.5, 5307.1 and 5307.3.

Labor Code

Labor Code section 5307.11

Where a contract for reimbursement rates exists, the contract rate applies instead of the OMFS.

From the decision · page 3Finally, conflating sections 4903.1(b) and 5307.11, lien claimant argues that a lien for emergency medical services is somehow different from other types of liens and should be paid pursuant to contract rates rather than the OMFS. Section 5307.11 pertains to contracts between a "health care provider" and "a contracting agent, employer or carrier" that "contracts for reimbursement rates different from those in the fee schedule adopted... pursuant to Section 5307.1." This section provides that where the contracted rate is different from the medical fee schedule, the medical fee schedule "shall not apply to the contracted reimbursement rate." If lien claimant has a relevant contract, it may seek payment under that contract. However, to the extent lien claimant is arguing that it should get paid its normal contract rates rather than pursuant to the OMFS, that position is not consistent with Section 5307.11.

ADJ11637452 · February 17, 2023

What the panel ordered

What was disputed, and how it came out

The facts that decided it

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The rules the panel named

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