How Medical Providers Can Maximize Their Ability to Recover PIP Benefits

Callagy Law attorneys are experts in maximizing health care providers’ recovery of Personal Injury Protection (“PIP”) benefits where the patient elected health insurance primary and the health carrier denied payment or issued only partial payment.

By way of background, when an insured elects health insurance as primary for PIP medical expense benefits, the medical expense benefits available to the insured under his or her automobile policy’s personal injury protection provision become secondary.  New Jersey law provides that an automobile insurer’s obligation to provide PIP benefits is limited to “allowable expenses” remaining uncovered after all health benefits plans for which the insured is eligible have paid benefits towards those allowable expenses.  In sum, when a health carrier asserts that it is not required to issue PIP medical expenses per the policy or law and, thus, will not act as the primary coverage provider, the automobile insurer shall thereafter assume the role of primary PIP coverage provider.  

In order to pursue a claim for PIP benefits on behalf of health care providers seeking reimbursement for their services where their patient elected health insurance primary, it is imperative that the health care provider follow the steps listed below:

·         First, submit bill(s) to the patient’s health carrier;

·         Second, if the health carrier denied payment or issued only partial payments, the health carrier’s Explanation of Benefit (“EOB”) form(s) need to be submitted to the patient’s automobile insurer;

An automobile insurer’s obligation to pay PIP benefits as secondary PIP insurer is triggered by the health carrier’s denial of the health provider’s bills and the denial is not required to be substantive in nature.  Examples of health care denials that have triggered an automobile carrier’s obligation to pay PIP benefits as secondary payor are set forth below:

·         Where the health carrier denied payment due to the fact that the patient failed to submit bills in a timely manner;

·         Where the health carrier denied payment on the grounds that the patient failed to obtain pre-authorization;

·         Where the health carrier’s EOB indicated that payment was “pending”  based upon a request for additional information from the patient which was never provided;

·         Where the health carrier’s EOB indicated that there is “positive no fault information on file, resubmit the claim with completed no fault letter information” and the requested information was never provided.

In sum, proper documentation will maximize health care providers’ success in recovering PIP reimbursement where the patient elected health insurance primary and the health insurer denied payment. 

Original Article:

http://callagylaw.com/medical-providers-can-maximize-ability-recover-pip-benefits/

For more information please visit:

www.callagylaw.com

www.callagycounsel.com

You may also be interested in reading our latest blog posts!

http://callagylaw.com/flexibility-another-necessity-client-liaison-effectiveness/

http://callagylaw.com/commercial-insurance-third-rail-medical-claim-recovery/

http://callagylaw.com/time-management-client-liaisons-key-good-customer-service/

Flexibility: Another Necessity for Client Liaison Effectiveness

A client liaison is called upon to service various types of medical providers–from surgeons to chiropractors, from surgery centers to hospitals, medical billing companies, pharmacies, and many others.  Even providers of a similar type can vary tremendously in the way they operate on a daily basis.  A liaison needs to adjust to the parameters set by the provider and accommodate any peculiarities associated with a particular practice, while at all times seeking to maximize the efficiency of “pulling” that provider’s files.

The type of provider presents the first variation.  Pulling files for a physical therapist is very different from pulling files for a surgery center.  For example, there are usually many fewer dates of service for a surgery center, with many fewer clinical documents.  There might be one or two operation reports needed for a surgery center file, whereas hundreds of pages of treatment notes might be necessary for the physical therapist claims.  Indeed, the physical therapist’s file might be a hodgepodge of denied, unpaid and underpaid dates of service, while the surgery center claim might consist of 2 dates both denied for medical necessity.

The manner in which the provider maintains the files adds a second level of variation to the process.  Some providers utilize electronic files, whereas others still use hardcopy patient charts with prong fasteners.  The electronic files are more efficient for the liaison but require training;  the hardcopy charts add significant time to the pulling process but places at the liaison’s immediate disposal everything available for that claim.

A third level of variation grows out of the provider’s preference for how involved they would like to be in the pulling process.  Some providers are known as working accounts, meaning the liaison will physically go into the provider’s systems, and, working from reports prepared by the provider, determine if a claim is arbitrable or not.  The report might send the liaison to carrier EOB’s (Explanations of Benefit), which in turn might prompt the liaison to review clinical records.   Other providers prefer to assemble the files themselves and send them to the liaison via email, fax, or schedule a pick up of files.  Either way, liaisons, on some occasions, are able to obtain all necessary information from one visit, or from one mailing, but on other occasions the liaison must make  a few trips to a provider’s or make a few  requests for additional information from provider office personnel.

Finally, providers, depending on the amount of files they generate in the course of a month, could warrant visits on a weekly, bi-weekly, or monthly basis, and still others might call for visits on an as needed basis.   It is the responsibility of liaisons to manage their schedules effectively to optimize the efficiency and quality of these services they perform.

Original Article:
http://callagylaw.com/flexibility-another-necessity-client-liaison-effectiveness/

For more information please visit:
www.callagylaw.comwww.callagycounsel.com

You may also be interested in reading our latest blog posts!
http://callagylaw.com/commercial-insurance-third-rail-medical-claim-recovery/http://callagylaw.com/time-management-client-liaisons-key-good-customer-service/http://callagylaw.com/initial-pip-patient-encounter-opportunity-obtain-proper-documentation-avoid-bill-denials-payment-delays/

x

Commercial Insurance—The Third Rail of Medical Claim Recovery

In the world of medical insurance claim recovery, medical treatment can be divided into three categories.  The first category relates to medical treatment arising from a motor vehicle accident and, for the most part, is governed by the Personal Injury Protection (PIP) or No-Fault laws.  The second category involves work place injuries, which are governed by the Workers Compensation (WC) laws and the way they affect WC insurance policies.  Relatively speaking, these two categories of claim are fairly straightforward.  Often it is apparent from a PIP or WC carrier Explanation of Benefits (EOB) whether a denial or underpayment merits arbitration or litigation.  Not so with the third category—Commercial Insurance (CI)—which we regard as the third rail of medical claim recovery.  The recovery potential of CI claims is often elusive and unpredictable, and the procedures necessary for recovery are often complex and time-consuming.

CI claims are most often governed by the insurance plan of the patient.  Most of the time the patient not only is unfamiliar with the specifics of their plan, but they often do not even have in their possession the details of the plan.  They might have some of the policy endorsements but hardly ever will they have available detailed payment terms and conditions for medical provider reimbursement.  Moreover, CI carriers usually are not very forthcoming with the plans when requested by the medical provider, even after repeated attempts to obtain the plan.  As a result, payments that are relatively low compared to the billed charges are often found to be consistent with the plan after months of effort and resources have been expended to obtain the plan.  Whereas the likelihood of recovery for PIP and WC claims often can be readily ascertained from a review of the EOB, Commercial Insurance claims often appear to be gross underpayments but are later found to be precisely what the patient’s plan called for.

In addition, from a procedural point of view, Commercial Insurance claims are far more complex than PIP or WC claims.  PIP and WC, for the most part, involve proceedings that are relatively informal, with more relaxed evidentiary rules and procedural requirements.  CI claims, on the other hand, are often resolved  in federal court, where the proceedings are much more formal.  The rules of procedure and evidence are much stricter; the time frames for resolution are much more protracted; and preliminary requirements, such as Assignments of Benefits (AOBs) and provider payment appeals, are given much closer scrutiny.  The result is a much more time-consuming process for dispute resolution.

Accordingly, CI is very different from PIP and WC, and seeking recovery without that realization can be a very frustrating and unrewarding exercise.  We believe in large measure we have overcome the pitfalls noted above.  We have developed a new approach to seeking recovery of these claims, an approach that is mutually beneficial for the medical provider and Callagy Law, and one which imposes no financial risk on our clients.   Our approach does not work with all types of providers, but it is one that we believe will prove successful with the types of providers who fit the model.
Contact us.  We would be happy to discuss whether your practice is the type of practice that is a good fit  for our new approach.

Original Post: 

http://callagylaw.com/commercial-insurance-third-rail-medical-claim-recovery/

For more information please visit:
www.callagylaw.com
www.callagycounsel.com 


You may also be interested in reading our latest blog posts!

http://callagylaw.com/seth-leibsohn-show-ft-sean-callagy/
http://callagylaw.com/first-amendment-work-unicorns-tale/
http://callagylaw.com/the-role-of-medical-documentation-in-new-jersey-pip/

Time Management for Client Liaisons: The Key to Good Customer Service

The foundation for being a successful client liaison is effective time management.  When client liaisons understand how long a task should take, they can manage their own schedule efficiently and better manage the client’s expectations.   

At the start, it is important to understand that client liaisons have a great deal of independence. Much of their time is spent in the field, because the role primarily involves hands-on interaction at the client’s location.   Liaisons are free to make their own schedule, and rightfully so, because only the liaison knows the schedules, workflows, and logistical preferences of the medical practices they service.  Accordingly, the ability to manage time effectively is not only important, but is fundamental to the role.

Client Liaisons are the bridge between the Law Firm and the provider’s medical facility, with the responsibility to keep the provider informed and updated about all their files, and to give the provider a sense of assurance that they are being serviced effectively.  However, spending too much time servicing a provider can be as detrimental to a liaison’s performance as spending too little time.  

The goal is to “pull” all the files that can be pulled as soon as possible, which means liaisons must have a good sense of how many files a particular provider generates each month, how much time is needed to work the files, and how often to visit to make sure those files are pulled.  The goal is to exhaust the provider’s monthly universe of files.  Every provider is different in terms of the number of files they generate, the nature of the files they generate, and the logistics of working those files.  Client liaisons need to determine the optimum amount of time to spend with each provider.  This optimization process benefits both the provider by identifying as many good claims as possible as quickly as possible, as well as the Law Firm by maximizing the business brought in to the Law Firm from that provider.

At the same time, the liaison must be careful about not neglecting smaller providers.  The liaison must be sensitive to the smaller provider’s needs and grant the smaller provider sufficient enough time and attention to feel like they too are important to the Law Firm.  A visit once per month might still only generate a small handful of files, but it might be necessary for effective customer service. 

Effective time management is the key to this process.  Of course, there are other elements a liaison must bring to the job—communication skills, knowledge of the client’s needs, responsiveness—but without good time-management skills a liaison will not perform well, regardless of how skilled the liaison is in other areas.

Original Post:

http://callagylaw.com/time-management-client-liaisons-key-good-customer-service/

For more information please visit:

www.callagylaw.com

www.callagycounsel.com

You may also be interested in reading our latest blog posts!

http://callagylaw.com/first-amendment-work-unicorns-tale/

http://callagylaw.com/the-role-of-medical-documentation-in-new-jersey-pip/

http://callagylaw.com/perfect-pip-file-need-want/

The Initial PIP Patient Encounter: An Opportunity to Obtain the Proper Documentation to Avoid Bill Denials and Payment Delays

The first priority for all health care providers is treating his or her patient.  However, when it comes to proper payment for that treatment, documentation to establish eligibility for PIP reimbursement is critical.  The first patient encounter results in an enormous amount of paperwork for both the PIP patient and the health care provider.  With so much documentation exchanging hands it is easy to miss documents that will be needed when time for payment comes around.  Here are a few ideas for documentation that will help make obtaining PIP payments for treatment run smoother.

Assignment of Benefits

First and foremost, the key document for PIP reimbursement is the Assignment of Benefits (“AOB”).  This document allows health care providers to obtain payment directly from insurance companies.  While all providers have some form of AOB, many contain language that is routinely challenged by insurance companies.  The language of anAOB should give the health care provider the right to obtain payment directly from the insurance company and to proceed through any other means available, such as through arbitration or the courts, in order to obtain payment.  This allows the health care provider to proceed to arbitration or lawsuit if the insurance company denies payment for any reason.  The AOB should have the health care provider’s name prominently displayed to show that it pertains to that specific health care provider.  It should also be clearly signed and dated by the patient or guardian with a printed name to avoid any ambiguities that the insurance company may see as a reason to deny payment.

PIP Application

Apart from the AOB, the PIP application is the most important document needed when seeking PIP benefits from an insurance company.  This document conveys much of the information the insurance company needs to establish eligibility for coverage including policy number, insured’s name, patient’s address, accident location, injuries, and lost wages.  Failure to provide this foundational document results in the denial of many claims.  This document acts as a first step in opening up a claim for a health care provider for PIP benefits.

HIPAA Release

Under the Health Insurance Portability and Accountability Act (“HIPAA”), patient privacy was made a byword for all health professions.  All health care providers take this requirement very seriously.  While maintaining the highest standards of privacy, at times the sharing of medical information is necessary for consistent continued treatment between health care providers and for legal professionals who seek PIP reimbursement for treatment performed.  A standard HIPAA release for medical information is a legal document that allows providers or legal professionals to obtain medical documentation to facilitate continued treatment and to provide records to show the “medical necessity” of treatment in order to obtain payment.

Many times a PIP patient is referred to one health care provider from another for the purpose of continuation of treatment.  This health care provider may need medical documentation that he or she does not already have.  In addition, when a legal professional is attempting to establish “medical necessity” for the treatment of one health care provider, it is necessary to have the medical records of another provider.  As a result, a HIPAA release is a valuable tool to obtain this documentation when needed.  It is recommended that during the initial patient visit, a HIPAA is signed and dated by the new patient, allowing you “and your legal representatives” to obtain medical records from other treating physicians or MRI facilities.

It is very important to explain to the patient what the release means when it is presented to them for signing and the limited uses for which the release can be utilized.

Affidavit of No Insurance

In many instances in PIP, the patient will be seeking benefits from someone else’s automobile insurance policy.  This occurs when a patient has no insurance of his or her own and is seeking PIP coverage through a resident relative or the owner of the vehicle in which he or she was an occupant.  When this occurs, the insurance company that is billed for treatment rendered is very curious as to what other coverage the patient may be entitled to.  To obtain this information, the insurance company will require an uninsured patient to sign an Affidavit of No Insurance (“AONI”).  The AONI is a sworn document contemporaneously signed by a Notary Public which identifies a patient’s address; whether he or she was a named insured under a policy of automobile insurance; who he or she lived with; the relationship to the patient; and whether any of those people with whom he or she lived had their own automobile insurance.  This is done in order to see if there is other coverage within the household that would be liable for payment of PIP benefits.  Many insurance companies will deny benefits to a provider if this documentation for such payments is not provided.

While not exhaustive, these documents will facilitate prompt payment of claims and avoid many eligibility issues that may arise.

Original Post: 

http://callagylaw.com/initial-pip-patient-encounter-opportunity-obtain-proper-documentation-avoid-bill-denials-payment-delays/

For more information please visit:

www.callagylaw.com

www.callagycounsel.com

You may also be interested in reading our latest blog posts!

http://callagylaw.com/5-contract-tips-avoiding-litigation/

http://callagylaw.com/ppo/

http://callagylaw.com/provider/

The First Amendment at Work: A Unicorn’s Tale

I was flipping between radio stations on the drive home one summer day when I heard my favorite sports radio host in a heated rant over freedom of speech. A football player, Don Jones of the Miami Dolphins, had been reprimanded by his team for a tweet he made. Though the host disagreed with Mr. Jones’s opinion, he was furious over the fact his first amendment rights were trampled. Caller after caller chimed in their displeasure about the Constitutional travesty that the Dolphins had committed. The future of the Country was in doubt!

But was there really a reason to be alarmed? A reading of The First Amendment should ease all the worries. The First Amendment of the United States Constitution states the following:

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.”

The text prohibits the government from restricting the freedom of speech. However, it does not prohibit private entities from taking action against their employees. The First Amendment applies to the government alone. Thus, if law enforcement arrested or fined Mr. Jones for his tweet, it would be a serious violation of his First Amendment rights. That’s not, however, what happened here.  We can breathe a little easier.

The truth is this situation should encourage us. The government didn’t interfere with Mr. Jones’s tweet and it didn't interfere with how the Dolphins decide to run their business. Freedom of speech was preserved. Thus, while saying your supervisor is a jerk won’t get you arrested, it could sure get you home sooner than you were expecting. Freedom of speech at work, unless you work for the government, does not exist.

Original Article:
http://callagylaw.com/first-amendment-work-unicorns-tale/

For more information please visit:
www.callagylaw.com
www.callagycounsel.com

You may also be interested in reading our latest blog posts!
http://callagylaw.com/5-contract-tips-avoiding-litigation/
http://callagylaw.com/ppo/
http://callagylaw.com/provider/

Help Us Help You: The Role of Medical Documentation in New Jersey PIP

When a medical provider treats a patient for injuries caused by a motor vehicle accident, the medical documentation will often determine if reimbursement is required by the auto insurer.  The provider has the burden to prove the treatment was medically necessary and reasonable.  Miltner v. Safeco Ins. Co. of Am., 175 N.J. Super. 156 (Law Div. 1980). Generally speaking, the provider must carry that burden by a preponderance of the evidence.

Pursuant to N.J.A.C. 11:3-4.2, “medically necessary” or “medical necessity” means that the medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person, and; (1) The treatment is the most appropriate level of service that is in accordance with the standards of good practice and standard professional treatment protocols including the Care Paths … as applicable; (2) The treatment of the injury is not primarily for the convenience of the injured person or provider; and (3) Does not include unnecessary testing and treatment. 

Focus on the phrase “clinically supported.”  This means the provider personally examined and evaluated the patient in making an assessment of the patient’s subjective and objective complaints, as well as considered prior test results and recorded all observations and findings.

It is imperative to recognize The New Jersey Department of Insurance and Banking (“DOBI”), the regulatory body for New Jersey PIP, has adopted Care Paths, which are “typical” courses of intervention in the treatment of a patient.  DOBI recognizes the Care Paths may vary, depending on the medical needs of the patient.  Deviations, however, must be properly documented to increase the likelihood of success at arbitration.  For example, a patient may have co-morbidities or pre-existing conditions requiring more or different treatment that would otherwise be typically provided, but this must be explained in the documentation by the treating doctor.

For example, let’s say a “typical” course of treatment for someone injured in a motor vehicle accident is x weeks of conservative care, such as chiropractic care.  If that patient has a co-morbidity that would require additional conservative care and the patient continues to improve with care, this additional care could generally be deemed medically necessary if the medical records support that position. 

Similarly, let’s say the patient remains symptomatic after a “typical” period of conservative treatment, and the “typical” course of treatment at that stage would be surgical intervention.  What if the patient does not want to undergo surgery at that time for reasons also explained in the medical record?  That important information might provide a reasonable basis to continue with conservative care and/or injection treatment.

Check the Medical Denials.  Auto insurers are required to have medical denials before they may properly deny treatment based on medical necessity.  N.J.A.C. 11:3-4.7(c)4 provides,  “All determinations on treatments or tests shall be based on medical necessity and shall not encourage over or underutilization of benefits.  Denials of decision point review and precertification requests on the basis of medical necessity shall be the determination of a physician.” 

Make sure medical denials address the requested treatment, and the insurer’s doctor is of the same specialty as the treating doctor.

Three day Rule.  Auto insurers are required to respond to a provider’s pre-certification request in three business days.  Check to see when the insurer responds to your request.  (Make sure you can prove the day your request was sent, and that it was sent to the proper facsimile number, etc. of the insurer.)  An untimely denial may be another way to show medical necessity of treatment.

In sum, the role of medical documentation in a New Jersey PIP arbitration is paramount.  If the treating doctor documents all clinical findings made by thorough evaluation and examination, and then explains the medical basis for recommended treatment, our chances of success are increased significantly.  As Jerry Maguire has so eloquently stated, “help us help you.”

Original Post:

http://callagylaw.com/the-role-of-medical-documentation-in-new-jersey-pip/

For more information please visit:

www.callagylaw.com

www.callagycounsel.com

You may also be interested in reading our latest blog posts!

http://callagylaw.com/2013-pip-regulations-lower-reimbursements-for-ascs/

http://callagylaw.com/5-contract-tips-avoiding-litigation/

http://callagylaw.com/ppo/