Authorities as the decision cited them, with how this panel applied each one.
Evidence from bill review expert regarding cost incurred by facility for particular procedure may be considered in determining reasonable fee.
Bill review expert evidence was considered relevant to determining reasonable cost basis.
Labor Code section 5909
A petition for reconsideration is deemed denied unless acted upon within 60 days from the date a trial judge transmits a case to the appeals board.
The Appeals Board must act on a petition for reconsideration within 60 days of transmission of the case to the Appeals Board.
From the decision · page 1Former Labor Code section 5909 provided that a petition for reconsideration was deemed
denied unless the Appeals Board acted on the petition within 60 days from the date of filing. (Lab.
Code, § 5909.) Effective July 2, 2024, Labor Code section 5909 was amended to state in relevant
part that:
Title VIII CCR section 9789.22(k)(5)
Long term care hospitals exempt from fee schedule are reimbursed on a reasonable cost basis pursuant to Title VIII CCR section 9789.22(k)(5).
The hospital gets reimbursed on a reasonable cost basis as it is exempt from the fee schedule.
From the decision · page 6It has been stipulated that the charges of Monrovia Memorial Hospital are exempt from the fee
schedule since it is a long-term care hospital. Thus the hospital gets reimbursed on a reasonable cost
basis pursuant to Title VIII CCR section 9789.22(k)(5). Since the term "reasonable cost basis" is not
defined in the rules, it has been held that long term care hospitals bear the same burden of proof as other
lien claimants that are exempt from the fee schedule. In other words, it must be shown that the charges
are reasonable (Collazo v. Meco-Nag Corp. (2017) (82 CCC 623)). As such, like other cases where the
fee schedule does not apply, the factors set forth in Kunz v. Patterson Floor Coverings (2002) 678 CCC
1588 (Appeals Board en banc) are relevant. Thus, the reasonableness of a fee is determined by
considering the medical provider's usual fee, the usual fee of other medical providers in the geographical
area in which the services were rendered, other aspects of the economics of the medical provider's
Kunz v. Patterson Floor Coverings (2002) 678 CCC 1588
Factors set forth in Kunz v. Patterson Floor Coverings (2002) 678 CCC 1588 are relevant to determining reasonable cost basis for lien claimants exempt from fee schedule.
The reasonableness of a fee is determined by considering the medical provider's usual fee, the usual fee of other providers in the area, economics of the provider's practice, and unusual circumstances.
From the decision · page 6It has been stipulated that the charges of Monrovia Memorial Hospital are exempt from the fee
schedule since it is a long-term care hospital. Thus the hospital gets reimbursed on a reasonable cost
basis pursuant to Title VIII CCR section 9789.22(k)(5). Since the term "reasonable cost basis" is not
defined in the rules, it has been held that long term care hospitals bear the same burden of proof as other
lien claimants that are exempt from the fee schedule. In other words, it must be shown that the charges
are reasonable (Collazo v. Meco-Nag Corp. (2017) (82 CCC 623)). As such, like other cases where the
fee schedule does not apply, the factors set forth in Kunz v. Patterson Floor Coverings (2002) 678 CCC
1588 (Appeals Board en banc) are relevant. Thus, the reasonableness of a fee is determined by
considering the medical provider's usual fee, the usual fee of other medical providers in the geographical
area in which the services were rendered, other aspects of the economics of the medical provider's