Durable Medical Equipment, Prosthetics, Orthotics, and Supplies When billing for Out-Patient Surgery-
Ocean View School District et al. v. Workers' Compensation Appeals Board B202630 Second Appellate District,
Division Six Nov. 26, 2007
8 Cal. Code Reg. § 9789.38(b), ''Determination of hospital outpatient prospective payment rates: Included costs,''
provides ''The prospective payment system establishes a national payment rate, standardized for geographic
wage differences, that includes operating and capital-related [*1685] costs that are directly related and integral to
performing a procedure or furnishing a service on an outpatient basis. In general, these costs include, but are not
limited to . . . '' (subsection 10) ''Durable medical equipment that is implantable.''
Section 9789.38 adopts the federal regulation (42 C.F.R. § 419.2) which addresses the practices of outpatient
facilities. It does not address the providers of durable medical equipment or restrict the number of mechanisms for
billing for durable medical equipment that is implantable.
Seeking reimbursement for the battery is not an attempt to ''enmesh the Petitioner in an internal billing dispute
between the Lien Claimant and the Outpatient Facility There is no internal billing dispute. If petitioner
contemplated that the battery was included when paying the surgery center, it was due to a failure to review and
contest the Spanish Hills bill.
In this case it is the equipment provider's billing and lien that is in issue. A restriction on the surgery center cannot
automatically be applied to bar recovery from a medical provider that is not subject to that regulation.
Ocean View School District et al. v. Workers' Compensation Appeals Board B202630 Second Appellate District,
Division Six Nov. 26, 2007
8 Cal. Code Reg. § 9789.38(b), ''Determination of hospital outpatient prospective payment rates: Included costs,''
provides ''The prospective payment system establishes a national payment rate, standardized for geographic
wage differences, that includes operating and capital-related [*1685] costs that are directly related and integral to
performing a procedure or furnishing a service on an outpatient basis. In general, these costs include, but are not
limited to . . . '' (subsection 10) ''Durable medical equipment that is implantable.''
Section 9789.38 adopts the federal regulation (42 C.F.R. § 419.2) which addresses the practices of outpatient
facilities. It does not address the providers of durable medical equipment or restrict the number of mechanisms for
billing for durable medical equipment that is implantable.
Seeking reimbursement for the battery is not an attempt to ''enmesh the Petitioner in an internal billing dispute
between the Lien Claimant and the Outpatient Facility There is no internal billing dispute. If petitioner
contemplated that the battery was included when paying the surgery center, it was due to a failure to review and
contest the Spanish Hills bill.
In this case it is the equipment provider's billing and lien that is in issue. A restriction on the surgery center cannot
automatically be applied to bar recovery from a medical provider that is not subject to that regulation.
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