SIGNIFICANT CASE SUMMARY

Pennsylvania Significant Case Summary

700 Pharmacy v. Bureau of Workers’ Comp. Fee Review Hearing Office (State Workers’ Ins. Fund)
Nos. 97-101 MAP 2024
Supreme Court of Pennsylvania

Decided: June 16, 2026

Pennsylvania Supreme Court holds that the Legislature did not intend to include prescription drugs as one of the “goods or services” prohibited by the Anti-Referral Provision of the Act.

Facts

The Anti-Referral Provision of the Act makes it unlawful for a provider to refer a person for “laboratory, physical therapy, rehabilitation, chiropractic, radiation oncology, psychometric, home infusion therapy or diagnostic imaging, goods or services” if the provider has a financial interest in the entity that receives the referral. (emphasis added). This Decision arises from consolidated Med Fee Reviews concerning whether providers violated the goods and services prong of the Anti-Referral Provision by prescribing drugs to be filled by pharmacies in which the providers owned a financial interest.

Holding

The Supreme Court held in favor of the providers, explaining that that reading “goods or services” as an independent catchall would render the eight enumerated services to be surplus. Of relevance to the Court was the Legislature’s inclusion of the word “or” between “home infusion therapy” and “diagnostic imaging,” concluding that the Legislature must have intended this to be a closed list.

Takeaway

Following this Decision, carriers may no longer deny prescriptions based on the Anti-Referral Provision where the prescribing doctor maintains an ownership in the pharmacy. Carriers maintain the right to deny payments based on the eight untouched items listed in the statute, which this Decision did not affect. Remaining remedies include challenging the reasonableness and necessity of prescriptions via utilization review and arguing against an entity’s status as a “medical provider,” where applicable since only medical providers have standing in fee review matters pursuant to Scomed.

Questions about this case can be directed to Cailey Farinaro, at 610-332-7008 or cfarinaro@tthlaw.com or Christopher Scott, at 717-2377111 or cscott@tthlaw.com.