Shawn Gooden and Lori Tunstall

    Prevailed before the Commonwealth Court. Claimant suffered a work-related injury when his right foot was run over by a tractor. He was transported by EMS personnel to a Level 2 trauma center. The EMS personnel, in their notes, indicated that Claimant’s acuity level was low and he was transported without lights and sirens. However, once in the emergency room, emergency room personnel performed a whole body CT scan and concluded that Claimant suffered a pubic ramus fracture and that there was a neurovascular compromise in his foot fracture and so he was taken to the emergency room and the trauma team was alerted.

    The provider submitted a bill seeking payment at 100% of its usual and customary charges as they deemed Claimant’s injury to be immediately urgent and life-threatening. The insurance carrier reduced the bill to the fee cap amount. The hospital disagreed with that determination and the case was taken to the Commonwealth Court for a decision.
    The Commonwealth Court once again affirmed that the determination as to whether an injury is immediately urgent and life-threatening is to be based on the judgment of the EMS personnel or first responders based upon the American College of Surgeons Triage Guidelines. If the EMS personnel or first responders conclude that the patient’s condition is immediately urgent and life-threatening and make the determination to transport the patient to a trauma facility, that judgment will be considered presumptive unless there is a clear showing of error. In this case, the EMS personnel concluded that Claimant’s condition was not immediately urgent and life-threatening and there was nothing in the record to infer that their determination was based upon such a conclusion. In addition, the decisions made by hospital personnel after conducting additional testing will not substitute for the determination of the EMS personnel and their initial assessment. At issue was over $85,000.00 in additional hospital charges.
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