Court Opinions

State Laws

US Code

US Constitution

Customary charges for treatment - 75 Pa. Cons. Stat. § 1797

Legal Research Home > Pennsylvania Statutes

     § 1797.  Customary charges for treatment.
        (a)  General rule.--A person or institution providing
     treatment, accommodations, products or services to an injured
     person for an injury covered by liability or uninsured and
     underinsured benefits or first party medical benefits, including
     extraordinary medical benefits, for a motor vehicle described in
     Subchapter B (relating to motor vehicle liability insurance
     first party benefits) shall not require, request or accept
     payment for the treatment, accommodations, products or services
     in excess of 110% of the prevailing charge at the 75th
     percentile; 110% of the applicable fee schedule, the recommended
     fee or the inflation index charge; or 110% of the diagnostic-
     related groups (DRG) payment; whichever pertains to the
     specialty service involved, determined to be applicable in this
     Commonwealth under the Medicare program for comparable services
     at the time the services were rendered, or the provider's usual
     and customary charge, whichever is less. The General Assembly
     finds that the reimbursement allowances applicable in the
     Commonwealth under the Medicare program are an appropriate basis
     to calculate payment for treatments, accommodations, products or
     services for injuries covered by liability or uninsured and
     underinsured benefits or first party medical benefits insurance.
     Future changes or additions to Medicare allowances are
     applicable under this section. If the commissioner determines
     that an allowance under the Medicare program is not reasonable,
     he may adopt a different allowance by regulation, which
     allowance shall be applied against the percentage limitation in
     this subsection. If a prevailing charge, fee schedule,
     recommended fee, inflation index charge or DRG payment has not
     been calculated under the Medicare program for a particular
     treatment, accommodation, product or service, the amount of the
     payment may not exceed 80% of the provider's usual and customary
     charge. If acute care is provided in an acute care facility to a
     patient with an immediately life-threatening or urgent injury by
     a Level I or Level II trauma center accredited by the
     Pennsylvania Trauma Systems Foundation under the act of July 3,
     1985 (P.L.164, No.45), known as the Emergency Medical Services
     Act, or to a major burn injury patient by a burn facility which
     meets all the service standards of the American Burn
     Association, the amount of payment may not exceed the usual and
     customary charge. Providers subject to this section may not bill
     the insured directly but must bill the insurer for a
     determination of the amount payable. The provider shall not bill
     or otherwise attempt to collect from the insured the difference
     between the provider's full charge and the amount paid by the
     insurer.
        (b)  Peer review plan for challenges to reasonableness and
     necessity of treatment.--
            (1)  Peer review plan.--Insurers shall contract jointly
        or separately with any peer review organization established
        for the purpose of evaluating treatment, health care
        services, products or accommodations provided to any injured
        person. Such evaluation shall be for the purpose of
        confirming that such treatment, products, services or
        accommodations conform to the professional standards of
        performance and are medically necessary. An insurer's
        challenge must be made to a PRO within 90 days of the
        insurer's receipt of the provider's bill for treatment or
        services or may be made at any time for continuing treatment
        or services.
            (2)  PRO reconsideration.--An insurer, provider or
        insured may request a reconsideration by the PRO of the PRO's
        initial determination. Such a request for reconsideration
        must be made within 30 days of the PRO's initial
        determination. If reconsideration is requested for the
        services of a physician or other licensed health care
        professional, then the reviewing individual must be, or the
        reviewing panel must include, an individual in the same
        specialty as the individual subject to review.
            (3)  Pending determinations by PRO.--If the insurer
        challenges within 30 days of receipt of a bill for medical
        treatment or rehabilitative services, the insurer need not
        pay the provider subject to the challenge until a
        determination has been made by the PRO. The insured may not
        be billed for any treatment, accommodations, products or
        services during the peer review process.
            (4)  Appeal to court.--A provider of medical treatment or
        rehabilitative services or merchandise or an insured may
        challenge before a court an insurer's refusal to pay for past
        or future medical treatment or rehabilitative services or
        merchandise, the reasonableness or necessity of which the
        insurer has not challenged before a PRO. Conduct considered
        to be wanton shall be subject to a payment of treble damages
        to the injured party.
            (5)  PRO determination in favor of provider or insured.--
        If a PRO determines that medical treatment or rehabilitative
        services or merchandise were medically necessary, the insurer
        must pay to the provider the outstanding amount plus interest
        at 12% per year on any amount withheld by the insurer pending
        PRO review.
            (6)  Court determination in favor of provider or
        insured.--If, pursuant to paragraph (4), a court determines
        that medical treatment or rehabilitative services or
        merchandise were medically necessary, the insurer must pay to
        the provider the outstanding amount plus interest at 12%, as
        well as the costs of the challenge and all attorney fees.
            (7)  Determination in favor of insurer.--If it is
        determined by a PRO or court that a provider has provided
        unnecessary medical treatment or rehabilitative services or
        merchandise or that future provision of such treatment,
        services or merchandise will be unnecessary, or both, the
        provider may not collect payment for the medically
        unnecessary treatment, services or merchandise. If the
        provider has collected such payment, it must return the
        amount paid plus interest at 12% per year within 30 days. In
        no case does the failure of the provider to return the
        payment obligate the insured to assume responsibility for
        payment for the treatment, services or merchandise.
        (c)  Review authorized.--By December 1, 1991, the Legislative
     Budget and Finance Committee shall commence a review of the
     impact of this section. Such review may be conducted biennially.
     (Feb. 12, 1984, P.L.53, No.12, eff. Oct. 1, 1984; Feb. 7, 1990,
     P.L.11, No.6, eff. Apr. 15, 1990)

        Cross References.  Section 1797 is referred to in section
     1712 of this title.

Last modified: November 27, 2007