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.”
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