Anyone who treats PIP patients is familiar with the requirement that all auto insurance carriers have called “pre-certification.” Essentially, this means that in order to be paid, a provider must submit a proposed plan of treatment to the carrier, and have it reviewed and approved by the carrier prior to the services being performed. Failure to submit the proper form in a timely manner results in a 50% penalty.
For the medical provider who sees PIP patients few and far between, this pre-certification requirement may seem burdensome, but for those medical providers for whom PIP patients are common, a good system and some good procedures make this requirement nothing more than a small hurdle.
What to do then, when a patient presents to a provider’s office with new symptoms that day, or, a provider discovers a new malady during a surgery, and a provider has to perform a procedure that was not previously anticipated?
This is where the “unforeseen procedure” comes into play. As Claimant’s counsel, we often successfully argue that a particular procedure was “unforeseen” prior to the treatment on that particular date, and therefore, the requirement of pre-certifying a certain code or procedure should be lifted, and a 50% penalty should not be applied.
Many of the arbitrators before whom we regularly appear have accepted this argument and do find that when, for example, a doctor starts a knee surgery, and discovers during the surgery that the patient has a torn meniscus, a fact which was previously unknown, the doctor should not be penalized 50% for repairing the torn meniscus when that service was not previously certified.
While these arguments of counsel are commonly accepted, medical providers can give themselves even more of a chance of avoiding the penalty if they include language in their medical records stating that the procedure was unforeseen, not anticipated, previously unknown, etc.
Further, a reference to an unforeseen procedure in an appeal (prior to filing arbitration) would also give great weight to an attorney arguing this position. Arbitrators are likely to turn to a carrier’s attorney and ask “What should the doctor have done? Sewed the patient up, pre-certified, and then re-opened them up?” And then the arbitrator is likely to render an award in favor of the medical provider.
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Pre-certification Penalties, PIP, and Unforeseen Procedures #Arbitration, #Callagylaw, #Pip, #Procedures, #Providers
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