State high court rules on pharmacy’s ability to challenge prescription
- June 1, 2025
- Posted by: Web workers
- Category: Workers Comp
The Supreme Court of Pennsylvania on Wednesday ruled that a pharmacy provider cannot challenge a utilization review determination that the medications it dispensed were unreasonable and unnecessary in a fee review proceeding, and that such providers do not have a due process right to notice and an opportunity to intervene in UR proceedings, either.
Thomas Shaw was working for the Roman Catholic Archdiocese of Philadelphia when he injured his knee in 2014. Keystone Rx LLC filled his prescriptions and billed the insurer, which in 2016 requested a utilization review of his medications, according to documents in Keystone RX LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office, filed in Harrisburg.
The UR concluded that the medications were “unreasonable and unnecessary.”
A later settlement agreement with the diocese resolved Mr. Shaw’s pending claims, which meant the insurer was not required to pay Keystone.
Keystone then filed for fee review. The Department of Labor and Industry determined that the insurer owed the pharmacy more than $4,000. In a hearing to contest, the Bureau of Workers’ Compensation Fee Review Hearing Office vacated the administrative determinations and dismissed Keystone’s applications.
The hearing office found that the insurer had met its burden of proving the medications were unreasonable and unnecessary and that the pharmacy did not have standing.
The Commonwealth Court affirmed, as did the Supreme Court in part, explaining that when “an insurer successfully challenges a treatment, the act makes clear that a non-treating provider does not have a constitutionally protected property interest in goods or services that it dispensed, as these providers were never entitled to payment under the act; rather, they simply have an expectation of payment in the normal course.… Absent a constitutionally protected property interest, there is no viable due process claim.”
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