Summary
concluding that medical expenses that are paid at workers’ compensation rates are presumptively reasonable because the statutory "worker's compensation fee schedules reflect customary market rates for medical services"
Summary of this case from State v. FugateOpinion
A165068
11-20-2019
STATE of Oregon, Plaintiff-Respondent, v. Christopher Lee WORKMAN, Defendant-Appellant.
Ernest G. Lannet, Chief Defender, Criminal Appellate Section, and Kristin A. Carveth, Deputy Public Defender, Office of Public Defense Services, filed the brief for appellant. Ellen F. Rosenblum, Attorney General, Benjamin Gutman, Solicitor General, and Michael A. Casper, Assistant Attorney General, filed the brief for respondent.
Ernest G. Lannet, Chief Defender, Criminal Appellate Section, and Kristin A. Carveth, Deputy Public Defender, Office of Public Defense Services, filed the brief for appellant.
Ellen F. Rosenblum, Attorney General, Benjamin Gutman, Solicitor General, and Michael A. Casper, Assistant Attorney General, filed the brief for respondent.
Before Lagesen, Presiding Judge, and James, Judge, and Haselton, Senior Judge.
LAGESEN, P. J.
Defendant was convicted of third-degree assault, ORS 163.165(2)(a), based on an Alford plea. The sentencing court imposed $8,274.84 in restitution, payable to the Crime Victims' Compensation Program (CVCP), for medical expenses that CVCP paid on behalf of the victim (a total of $5,154.84), and lost wages ($3,120) that CVCP paid to the victim. On appeal, defendant challenges the award of restitution for the medical expenses, contending that, under State v. McClelland , 278 Or. App. 138, 372 P.3d 614, rev. den. , 360 Or. 423, 383 P.3d 862 (2016), there is insufficient evidence to support a finding that the claimed medical expenses were reasonable. On review for legal error, State v. Campbell , 296 Or. App. 22, 26, 438 P.3d 448 (2019), we affirm.
"An Alford plea is a guilty plea in which the defendant does not admit commission of the criminal act or asserts that he is innocent. In such a situation, the trial court must determine that there is a factual basis for the plea." State v. Sullivan , 197 Or. App. 26, 28 n. 1, 104 P.3d 636 (2005), rev. den. , 340 Or. 673, 136 P.3d 743 (2006) (emphasis in original).
ORS 137.103(4)(c) provides that the "Crime Injuries Compensation Account" qualifies as a "victim" entitled to receive restitution "if it has expended moneys on behalf" of "[t]he person or decedent against whom the defendant committed the criminal offense, if the court determines that the person or decedent has suffered or did suffer economic damages as a result of the offense."
--------
When the state seeks restitution for amounts paid for medical charges, it must prove that the charges were reasonable. ORS 137.103(2) ; ORS 31.710 ; McClelland , 278 Or. App. at 143-44, 372 P.3d 614. A medical charge is reasonable if it is at (or below) the market rate for the services, drugs, or other medical items provided: "[T]he market rate is a reasonable amount for a victim to recover for medical expenses." Campbell , 296 Or. App. at 30, 438 P.3d 448. Medical bills, standing alone, are insufficient to prove that the charges reflected therein are market rate (or below) and, therefore, reasonable for purposes of the restitution statutes. State v. J. M. E. , 299 Or. App. 483, 487, 451 P.3d 1018 (2019). Rather, "[s]ome additional testimony or evidence is required to support the reasonableness of the bill for the hospital or medical services." McClelland , 278 Or. App. at 144, 372 P.3d 614. As we recognized in Campbell , that additional evidence may consist of evidence that the medical charges for which restitution is sought "were at or below the usual and customary rate for those services in that market." 296 Or. App. at 32, 438 P.3d 448.
Although defendant argues otherwise, this is not a case in which the trial court awarded restitution for medical charges based on bills alone. At the restitution hearing, the state called Shaw, the manager of CVCP. She testified that, before paying medical expenses, CVCP would review the bill, the chart notes, and, in the case of a victim with insurance, the explanation of benefits. She testified further that the amounts it paid for the victim's medical expenses were for hospital bills, doctor bills, and bills for medication. Most significantly with respect to the issue of reasonableness, Shaw explained that CVCP "did not pay the majority of those bills at 100 percent." Instead, at least when the victim is uninsured, CVCP pays medical charges using the workers' compensation fee schedule for medical services. In this case, the victim was uninsured and CVCP, in fact, paid the medical charges at issue in accordance with the workers' compensation fee schedules, writing off amounts that exceeded what was allowed by the fee schedule.
That evidence is sufficient to support a finding that the medical charges for which restitution was sought in this case were at or below market rate and, therefore, reasonable. By statute, ORS 656.248, the rates contained in Oregon's workers' compensation fee schedules "shall represent the reimbursement generally received for the services provided" and must be based on "any one or all of the following" types of information about the medical services market:
"(a) The current procedural codes and relative value units of the Department of Health and Human Services Medicare Fee Schedules for all medical service provider services included therein;
"(b) The average rates of fee schedules of the Oregon health insurance industry;
"(c) A reasonable rate of markup for the sale of medical devices or other medical services;
"(d) A commonly used and accepted medical service fee schedule; or
"(e) The actual cost of providing medical services."
In view of those statutory requirements, it can be inferred that workers' compensation fee schedules reflect customary market rates for medical services and, consequently, that medical charges paid at those rates, as happened here, were reasonable. The trial court did not err in awarding restitution for the claimed medical expenses on this record.
We observe that our recent decision in J. M. E. , 299 Or. App. at 488-89, 451 P.3d 1018, which also involved restitution payable to CVCP, is not to the contrary. In that case, "[n]o witness testified that the amount charged—or the amount subsequently paid by CVCP—was at or below the market rate for those services, nor was there any other evidence as to the reasonableness of the medical bill." Id . at 488, 451 P.3d 1018. Here, by contrast, the state introduced the type of evidence omitted in J. M. E. —testimony that the charges were paid in accordance with the workers' compensation fee schedule. That evidence, as noted, allows for the conclusion that the amounts paid were reasonable.
Affirmed.