Argued and submitted on June 11, 2012.
Department of Consumer and Business Services 0900090H, 0900015H, 0900016H, 0900107H, 0900009H, 0900085H
Diana E. Godwin argued the cause and filed the briefs for petitioners.
Stephen F. Deatherage argued the cause for respondent Hartford Casualty Insurance Company. With him on the brief were Ronald J. Clark and Bullivant Houser Bailey PC.
Judy C. Lucas, Senior Assistant Attorney General, argued the cause for respondent Department of Consumer and Business Services. With her on the brief were John R.
Kroger, Attorney General, and Anna M. Joyce, Solicitor General.
Neil W. Jones waived appearance for respondent Specialty Risk Services.
Before Ortega, Presiding Judge, and Sercombe, Judge, and Brewer, Judge pro tempore.
ORTEGA, P. J.
This case involves a medical fee dispute in which Cascade challenges the fees paid by insurer for medical services that Cascade provided to injured workers between January 2006 and May 2008. Cascade seeks judicial review of a final order in which the director of the Department of Consumer and Business Services (DCBS) concluded, after a contested case hearing, that insurer was not required to pay Cascade any additional amounts for the medical services at issue. On review, Cascade asserts that the director reached that conclusion based on an erroneous interpretation of OAR 436-009-0040(1) (01/01/08). We conclude that the director's interpretation of OAR 436-009-0040(1) was plausible, and we therefore affirm the order.
The relevant background facts were stipulated before the agency. At the time of the medical services at issue, Cascade had an existing contract (the provider contract) with First Health Group Corporation or its successor (the PPO organization) to participate in its preferred provider panel. Under the provider contract, Cascade agreed to accept a reduction in its usual and customary fees for clients of the PPO organization. The provider contract stated that the PPO organization intended to market its agreement to "various health insurance plans, indemnity insurers and workers' compensation insurers." At the time of the medical services in question, insurer was a client of the PPO organization; that is, it "had a valid contract with [the PPO organization] under the terms of which a percentage of, or all of, the discounted fees agreed to by [Cascade] and [the PPO organization] were made available to" insurer (the PPO contract).
Between January 2006 and May 2008, pursuant to compensable workers' compensation claims, Cascade provided reasonable, necessary, and authorized medical services to injured workers. Cascade then billed for those services at its usual and customary rate. However, insurer paid Cascade's bills at a lesser rate in accordance with the provider and PPO contracts. The differences between the amount billed by Cascade and the lesser amount paid by insurer are the basis for the dispute in this case--"whether insurer [was] authorized to discount payments to [Cascade] for billed fees based on a fee discount contract between [Cascade] and [the PPO organization]."
The Workers' Compensation Division's Resolution Team (resolution team) issued an administrative order in which it concluded that insurer had properly applied the discounts based on the provider and PPO contracts and, therefore, did not owe Cascade any additional payment. Cascade then requested a hearing.
Ultimately, the director, like the resolution team, resolved the dispute in favor of insurer, concluding that "fee discount contracts between providers and insurers were permitted" under the applicable ...