Sean Callagy - Attorney and Entrepreneur: arbitration

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Monday, May 9, 2016

What is No-Fault Auto Insurance and How does the Arbitration Process Relate?

The purpose of this post is to help assist those with questions they have concerning their business or medical practice. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. We hope to have this blog shed a light on many common questions.

One of the primary functions of Callagy Law, P.C. is the representation of New Jersey medical providers for collection of unpaid medical bills incurred as the result of motor vehicle accidents, which operates within the construct of what is called “Personal Injury Protection.”

To understand the relationships at play, the first thing to understand is that under New Jersey Law, all operators of Motor Vehicles must carry automobile insurance. This insurance can be obtained in two forms, “liability only,” or “liability plus collision.” The difference between the two is that the former is limited to payment of vehicular damage of another party’s vehicle – should it be determined that the accident was your fault. The latter includes coverage for damage to your own car in addition to damage caused to another person’s.

However, what many people do not realize is that, if you are injured as a result of a motor vehicle accident, the primary payor (i.e. insurance company) will typically default to your automobile insurance, not any personal health insurance that you may have. This is termed as the PIP coverage portion of your automobile insurance.

If a party is injured in an accident, their default payor will be their own car insurance company, not the other party involved in the accident, even if you feel the accident was caused by them. This is because New Jersey is one (1) of twelve (12) “No-Fault” states.

Specifically, the term “no-fault” auto insurance generally refers to any auto insurance plan that allows policyholders to recover reimbursement from their own insurance company, regardless of fault. However, the State of New Jersey utilizes the strictest definition of no-fault coverage, which provide for the payment of no-fault first-party benefits and restrict the right to sue any third parties with regard to the accident. As noted above, this “policyholder benefit coverage” is known as personal injury protection (PIP). [See: Insurance Information Institute, “No Fault Auto Insurance”- http://www.iii.org/issue-update/no-fault-auto-insurance]

Currently 12 states and Puerto Rico have no-fault auto insurance laws. Florida, Michigan, New Jersey, New York and Pennsylvania have verbal thresholds of PIP coverage. However, in New Jersey, Pennsylvania and Kentucky only, motorists may reject the lawsuit threshold and retain the right to sue for any auto-related injury. [Id.]

Therefore, in the most typical situation, when a patient is injured, and requires medical treatment, their personal car insurance company is responsible for making the appropriate covered payments. However, in many cases, the insurance companies’ unjustly deny payment based on purely procedural or theoretical grounds, or based upon differences in medical opinions between the patient’s doctors’ and the insurance companies’ hired “physician experts.”

Therefore, to take the burden of establishing the medical necessity of post-accident treatment, most patients “Assign” their right to payment to the physicians, who must then seek to recover any underpayments on their own accord, as subrogee of the insured patient. In order to protect their right to payment, the matters of PIP disputes are contractually stipulated to take place within an authorized New Jersey Arbitration Forum, rather than the more costly State Judicial System (ie Court).

At present, a company called “Forthright” administers New Jersey No-Fault Arbitrations, wherein its sole focus is management of No-Fault PIP Arbitrations under the State’s Automobile Insurance Cost Reduction Act. [See http://www.nj-no-fault.com/]

Callagy Law, P.C. represents all facets of medical providers from all stages of the arbitration process. We pick up your unpaid files, file the Demand for Arbitration, and send one of our highly skilled PIP-Litigation Specialized Attorneys to the scheduled hearing, where the provider’s argument for payment is presented to a Forthright Dispute Resolution Professional, who will subsequently render a decision, awarding the unpaid medical provider the fees to which they feel it is entitled. To date, almost $135,000,000.00 has been recovered for our PIP clients, a result of our 90% Claim Success Rate in the 44,000 cases that have been handled to date.

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What is No-Fault Auto Insurance and How does the Arbitration Process Relate? #Arbitration, #DemandForArbitration, #NoFault, #Pip

Friday, April 1, 2016

Decision Point Review Plans and Their Significance

In Part 1 of this series, we discussed Decision Point Review Plans (DPRP’s) and how they relate to pre-certification of medical treatment. There, we explained how understanding DPRP’s is critical to any medical provider who sees patients injured as a result of a motor vehicle accident (MVA). You will recall that DPRP’s are required to be filed with the State of New Jersey by carriers who write insurance policies governed by the New Jersey No-Fault laws, otherwise known as PIP, or Personal Injury Protection, and that DPRP’s are filed with the state by PIP insurance carriers in order to set forth the substantive and procedural requirements needed for a medical provider to be reimbursed by the PIP carrier. DPRP’s enable carriers not only to set forth how and when claims should be submitted, but also, among other things, to regulate specific diagnostic tests and apply additional deductible or co-pay penalties for failure to comply.

In Part 2 of our discussion, we focus on payment appeal procedures. Basically, any medical provider can appeal underpaid, denied or unpaid PIP claims with the PIP carrier or a carrier-approved third-party vendor. It is the first step in the dispute resolution process, which might end in PIP arbitration. You should proceed carefully with this step because failure to appeal properly can result in a denial from the arbitrator at PIP arbitration. All approved DPRP’s have specific procedures for appealing payments and they vary widely from carrier to carrier. Let’s look at three key areas of difference.

First, some carriers require a specific form for use with appeals; others do not. The DPRP will include a copy of the form. Complete the form as required, paying close attention to the accuracy of the information you provide. Mistakes could cost you in the end. If a particular carrier does not require use of a specific appeal form, you can use your own form, as long as it contains all of the requisite claim information and enough detail as to why you are appealing the payment or non-payment.

Second, proper delivery of the appeal is critical. DPRP’s often include a description of the appeal delivery vehicle. Some require faxing. Some require certified mail. Some require regular mail. All DPRP’s will explain the appeal delivery process they require including addresses and fax numbers. Some DPRP’s will require two levels of appeal, and the fax number for the first level might be different from the second level fax number.

Third, it is essential to wait the proper amount of time after appealing before filing for arbitration. Every carrier requires a specific time to lapse after you appeal, and filing too soon might result in a denial at arbitration.

If your head is starting to spin from trying to fathom all of the variations in procedures among the dozens and dozens of New Jersey PIP carriers, take heart. Knowing all of this, and doing the payment appeals for you to ensure all of the t’s are crossed and i’s are dotted, Callagy Law is standing by. We manage the labyrinthine payment appeals process for you to ensure that carriers, who intentionally look to complicate the process, do not benefit from this undue complexity. Payment appeal procedures are not to be taken lightly, and not understanding or following the correct process can be a grave financial mistake.

We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $185,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

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Decision Point Review Plans and Their Significance #Arbitration, #CallagyLaw, #Dprp, #Legal, #LegalNews, #Pip

Tuesday, November 17, 2015

PIP ARBITRATION PRACTICE TIP | CALLAGY LAW

THE IMPORTANCE OF FILING INTERNAL APPEALS PRIOR TO FILING A DEMAND FOR ARBITRATION

The purpose of this post is to help assist healthcare providers and owners with questions they have concerning their business or relevant knowledge in the field. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, andCommercial Insurance. We hope to have this blog shed a light on many common questions.

One of the most common defenses raised by insurance carriers as a basis to deny a medical provider’s claim for personal injury protection (“PIP”) benefits is failure to file internal appeals. Prior to filing a Demand for Arbitration on assignment from a patient, medical providers must comply with the PIP insurer’s internal appeal process. Thus, it is of critical importance for medical providers to abide by the PIP insurer’s internal appeal requirements, which can be found in the insurer’s Decision Point Review Plan (“DPRP”). Insurers generally forward their DPRP to treating medical providers after receipt of the treating provider’s 21 day notice letter.

The controlling regulation , N.J.A.C. 11:3-4.7(d)(8), requires that informational materials for policyholders, injured persons and treating medical providers shall include particular information including an explanation of the alternatives available to the provider if reimbursement for a proposed treatment, diagnostic test or durable medical requirement is denied or modified, including the insurer’s internal appeal process and how to use it. If the insurer does not have proof that it sent a copy of its DPRP to the patient and/or treating medical provider, it may lose the right to assert the defense of failure to file an internal appeal based on the fact that there was a lack of notice to the patient and/or treating medical provider of the internal appeals process.

It is important to review the PIP insurer’s internal appeals process since carriers have different requirements regarding whether both a 1^st and 2^nd level internal appeal must be filed, the deadlines for filing same and whether the appeal can be faxed or must be sent by regular mail or certified mail to a specific address listed in the DPRP. Medical providers must retain written proof that they forwarded the internal appeal(s) in compliance with the DPRP requirements, which can be by facsimile confirmation or certified mail return receipt.

There are two different types of internal appeals: (1) an appeal of an adverse determination based on lack of medical necessity and (2) an appeal of non-payments or under-payments, which can be based upon any of the following grounds:

Causation

Improper coding or down-coding of services

Usual, customary and reasonable rates

Lack of documentation

Coverage issues such as lack of cooperation

Improper pre-certification penalties.

Medical providers should keep in mind the importance of listing all potential bases of their appeal since the information listed on the appeal governs and may limit the arguments that may be raised in a later PIP arbitration proceeding.

In sum, medical providers should pay close attention to a PIP insurer’s DPRP plan’s internal appeal requirements. When an insurer denies treatment, a medical provider should promptly file an internal appeal of the denial to protect its rights to proceed to PIP arbitration.

We hope you have found this information helpful and interesting. Please reach out to us here with any questions or comments regarding healthcare legal matters, or if you are a medical provider that has questions regarding Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Feel free to search us on Facebook, Twitter or LinkedIn!

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PIP ARBITRATION PRACTICE TIP | CALLAGY LAW #Arbitration, #CallagyLaw, #Causation, #Claims, #Coverage, #Dprp, #HealthcareLawServices, #PipArbitration, #PipLitigation, #SeanRCallagy

Tuesday, November 3, 2015

PPO Contracts and PIP Arbitration | Callagy Law

The purpose of this post is to help assist healthcare providers and owners with questions they have concerning their business or relevant knowledge in the field. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. We hope to have this blog shed a light on many common questions.

N.J.A.C. 11:3-29.1(b) “. . . establish(s) medical fee schedules on a regional basis for the reimbursement of health care providers providing services or equipment for medical expense benefits for which payment is required to be made by automobile insurers under PIP coverage and by motor bus insurers under medical expense benefits coverage.”

However, medical providers often participate in a preferred provider organization, commonly referred to as a “PPO” agreement. Simply, medical providers participate in PPO agreements and accept discounted payments in exchange for certain benefits outlined in the contract.

Payment disputes often arise when an insurance carrier pays PIP coverage benefits in according to the PIP Fee Schedule Rates instead of according to the PPO discount rates. When an insurance carrier and a medical provider cannot settle such disputes, the medical provider may elect to have the matter resolved in binding arbitration, a forum administered by the New Jersey Department of Banking and Insurance (DOBI). Such matters are decided by a Dispute Resolution Professional (DRP).

Often, claimant medical providers argue that any improper PIP coverage payments constitute a violation of the PPO payment terms, resulting in a loss of the PPO discount. Suppose the PPO contract allows the insurance carrier to take a 20% discount of the billed charges, but payment was made per the PIP Fee Schedule. If DOBI regulations provide for payment to be made according to billed charges, then the claimant was entitled to payment at 80% of the billed charges, as outlined by the PPO contract in this scenario. In arbitration, the medical provider may seek the full amount of the billed charges, if the PPO contract allows for such redress.

Recently, a DRP agreed with this position in the matter Meadowlands Hospital a/s/o Walter Martinez v. GEICO (NJ-1540551). The DRP made the following finding:

Based upon a review of the record evidence, claimant’s argument is meritorious. . . . respondent did not pay claimant at 65% of the charges but rather inexplicably paid this facility at the New Jersey Physician’s Fee Schedule for CPT code 62310 and 62311. Clearly, this action was in violation of the terms of the PPO agreements and respondent loses the benefit of the PPO contract reduced payment rate. Claimant is awarded the balance sought for CPT codes 62310 and 62311 . . .

Similarly, in Raritan Bay Medical Center a/s/o D.H. v. GEICO (NJ-1596762), the DRP decided that the respondent insurance carrier had “failed to issue proper reimbursement . . . [, and] that the PPO Agreement states that Respondent is not permitted to apply any discount and Claimant is entitled to receive 100% of billed charges. Claimant is awarded $11,777.45 for codes 70450, 70486 and 72125.”

In NJ-1596762, the DRP construed the PPO contract as requiring the insurance carrier to issue payments within 30 days of receipt, per the contract’s payment terms. Because the insurance carrier issued payment per the PIP Fee Schedule instead of the PPO discounted rate, the DRP found contact payment terms were violated, resulting in the discount being forfeited.

Careful review of a PPO contract payment terms is essential for any medical provider participating in an binding arbitration.

PPO Contracts and PIP Arbitration | Callagy Law #Arbitration, #CallagyLaw, #Laws, #PipArbitration, #Ppo, #SeanCallagy

Thursday, April 30, 2015

Pre-certification Penalties, PIP, and Unforeseen Procedures

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