Tackling the Continued Tsunami of Medical Provider Bill Disputes
In Virginia we are continuing to see a good number of Applications advanced by medical providers alleging medical reimbursement disputes. Many of these are involving prescription reimbursements.
Just days ago, on August 7, 2025 the Full Commission released two Opinions related to medical provider fee disputes—Wil Hanson v. YMCA of South Hampton Roads, JCN: VA00000493234 (August 7, 2025) and Dyson v. Chesterfield County Public Schools, JCN: 1848504 (August 7, 2025). Both of these Opinions highlight some important strategies for employers and carriers to keep in mind with these cases.
It appears to this author that the Commission remains frustrated with the number of claims being pursued. The Full Commission noted in Hanson that while deeming a medical bill prima facie evidence of reasonableness undoubtedly protects claimants’ right to receive medical treatment, “it [does] nothing to protect the Commission from a tsunami of litigation compelling [them] to wrestle with a number of competing issues having nothing to do with whether the claimant [is] receiving awarded treatment.” The Full Commission noted further in Hanson that the case brought by the medical provider was “manufacturing a dispute where none exists.” This author continues to believe that it is high time that the Virginia legislature include prescription drugs in the Fee Schedule like we see in many states throughout the country.
I wrote an article back in 2023 entitled, “Combatting Escalating Prescription Costs in Virginia” discussing strategies for employers and carriers in combating the escalating prescription costs in Virginia. The tips set forth therein continue to apply and the abuse by some medical providers continues.
In Hanson the Full Commission affirmed the denial of balances asserted by three medical providers finding that the claimant failed to establish that any amount remained outstanding on the subject bills and that claimant failed to prove that the charges did not exceed the prevailing community rate. The Full Commission observed in Hanson that “[a]s a threshold matter, a party seeking reimbursement of medical expenses must establish payment is owed for the treatment at issue.” (Citation omitted). In short, the evidence did not demonstrate the existence of a debt for services rendered.
The Dyson decision dealt with the statute of limitations set forth in Virginia Code § 65.2-605.1 and the issue of standing. The Deputy Commissioner ruled that the claim brought by the medical provider was untimely. The Full Commission vacated this finding and remanded to the Deputy Commissioner. The Full Commission held that the claim of the medical provider was timely; however, the Full Commission remanded on the topic of standing. The Full Commission made it clear that the 1-year period runs from the date the medical provider was last paid for treatment rendered to the claimant. The matter was remanded to determine standing. The evidence revealed that the medical provider in this case, Integrative Pain Specialists, was under contract with StreamCare, LLC and that StreamCare purchased medications from third-parties which were then shipped directly to Integrative Pain Specialists. After those medications were prescribed and dispensed by Integrative Pain Specialists, StreamCare issued bills for those medications to the responsible insurance carriers who paid StreamCare directly.
In addition to the tips I offered back in 2023, the most recent Opinions released on August 7, 2025 highlight some additional tips for employers and carriers dealing with reimbursement issues that include the following:
1. Recognize that any payment you make to the provider may open the door for an Application up until 1-year following said payment.
2. When you go to settle a case, be sure that your attorney identifies in the Order that you are extinguishing all claims for non-payment or underpayment of any medical services rendered to the claimant.
3. Be sure to evaluate the issue of indebtedness. In other words, has the medical provider, indeed, asserted that a debt exists related to non-payment or underpayment of medical bills.
4. Evaluate the issue of standing. Can an argument be made that the medical provider asserting the claim does not have standing to bring the action?
The attorneys at Ford Richardson are routinely engaged by employers and carriers across Virginia to address workers’ compensation issues including, but not limited to acting as dedicated cost containment counsel on medical billing issues. Should you have any questions about the issues set forth above or any other legal issues, please do not hesitate to contact this author or any of the other lawyers at Ford Richardson.
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