Sean Callagy - Attorney and Entrepreneur: dobi

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Friday, April 29, 2016

Are MRI’s Reimbursable | Callagy Law

MRIs can be performed within five days of the insured event under certain circumstances

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.

Magnetic resonance imaging (MRI) is a test not normally performed within five days of the insured event. As a result, some insurance carriers will attempt to argue that these tests are not medically necessary and therefore, not reimbursable. However, clinically supported indication of neurological gross motor deficits, incontinence or acute nerve root compression with neurologic symptoms may justify MRI testing during the acute phase immediately post injury

In N.J. Coal. of Health Care v. Dept. of Banking & Ins., 323 N.J. Super. 207 (App. Div. 1999) at 247, the Court found that “[f]or cervical, thoracic and lumbar-sacral spine injuries, the first step in treating a patient involves, and logically so, a clinical evaluation by the appropriate health-care provider. Such an evaluation may include x-rays, CT scan, and an MRI, if necessary.”

Moreover, N.J.A.C. 11:3-4.5 (b) (5) states that these tests have been determined to have value in the evaluation of injuries, the diagnosis and development of a treatment plan for persons injured in a covered accident, when medically necessary and consistent with clinically supported findings, when used in accordance with the guidelines contained in the American College of Radiology, Appropriateness Criteria to evaluate injuries in numerous parts of the body, particularly the assessment of nerve root compression and/or motor loss.

The MRI test uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. The area of the body being studied is placed inside a special machine that contains a strong magnet. Pictures from an MRI scan are digital images that can be saved and stored on a computer for more study. The images also can be reviewed remotely, such as in a clinic or an operating room. In some cases, contrast material may be used during the MRI scan to show certain structures more clearly.

In many cases, MRI gives different information about structures in the body than can be seen with an X-ray, ultrasound, or computed tomography (CT) scan. MRI also may show problems that cannot be seen with other imaging methods.

According to the American College of Radiology, MRI testing should be reserved for cases of known or suspected soft tissue injuries such as disc herniations, ligament tears, epidural hematoma and spinal cord edema or hematoma, especially in the presence of a neurological deficit.

In Care Paths 1 and 5 for soft tissue injuries to the cervical spine and lumbar-sacral spine, respectively, though, an MRI may be administered if there are abnormal neurologic findings (i.e.: radiculopathy) and typically following a course of four weeks conservative treatment with no improvement in symptoms. In Care Paths 2 and 6 for soft tissue injuries to the cervical spine and lumbar-sacral spine with symptoms of radiculopathy, a minimum of two weeks conservative treatment without improvement in symptoms is recommended before administering an MRI.

As the MRI testing is appropriate during the clinical and diagnostic evaluation of injuries to the cervical and lumbar spine, especially if there are abnormal neurologic findings; these tests are in fact reimbursable if performed within five days of the insured event.

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 $200,000,000 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.

Learn More About Callagy Law Here:

Are MRI’s Reimbursable | Callagy Law #CallagyLaw, #Dobi, #HealthcareRecovery, #MagneticResonanceImaging, #Mri, #NjCoalOfHealthCare, #Recovery, #Reimbursable, #Reimbursement, #XRay, #Xray

Wednesday, March 23, 2016

Facility Fees vs. Physician’s Fees

The purpose of this post is to help assist healthcare providers and the public with questions they have concerning topics related to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. The Callagy Law team is knowledgeable in all aspects of these sorts of legal matters and will frequently post topics in this field. We hope to have this article shine a light on many common questions.

In the heavily regulated world of PIP (personal injury protection), it is important to distinguish between facility fees and physician’s fees, to ensure that, as a medical provider, you are receiving the appropriate form of reimbursement.

In New Jersey, auto insurers are required to provide a minimum of $15,000 in PIP coverage to everyone they insure. In practice, the amount tends to be much higher as the default option for PIP coverage is typically $250,000. To guard against endless PIP claims leading to ever increasing insurance premiums, the Department of Banking and Insurance (DOBI) promulgates fee schedules which essentially cap the amount of reimbursement providers can receive for the treatment they perform.

What is important to be mindful of is that there are many different kinds of healthcare providers and, in recognizing this concept, DOBI has set forth various different fee schedule rates.

The simplest example of different providers receiving different amounts of reimbursement for the same treatment performed is a physician versus a facility. It is somewhat intuitive that a facility charge is distinct from a physician charge and the fee schedules put forth by DOBI take this into account.

What further confuses this issue is the fact that, even within the category of facility charges, there are several different types of facilities. This too is accounted for by DOBI which distinguishes between various types of facilities.

For the most part, a facility charging a fee for medical services that it hosted, fits into one of three categories: a hospital, an ambulatory surgical center (ASC), or “other” (pretty much anything else).

The fee schedule rates for these various charges can be found on the DOBI website using the following link: http://www.state.nj.us/dobi/pipinfo/aicrapg.htm. Exhibit 1 contains a column titled “physician’s fees” and a separate column titled “ASC fees.” Thus, it is pretty simple to search and find the proper reimbursement for a physician charge or an ASC facility charge.

With respect to the “other” facility category previously mentioned, meaning facilities that are neither an ASC nor a hospital, the facility fees can also be found in Exhibit 1- they are listed in the physician’s fee column but they include the TC modifier (technical component). So, for example, let’s say a patient undergoes an X-ray of the jaw which is billed under CPT Code 70100. The “physician’s fee column” lists this CPT Code twice- once with the 26 modifier and once with the TC modifier. (To be complete, it also lists it a third time without any modifier which represents a global fee but that is beyond the scope of this article.) Assuming the CPT Code is being billed twice, once by a physician and once by a facility, the physician would bill with the 26 modifier and receive the corresponding fee schedule reimbursement, while the facility would bill with the TC modifier and receive payment accordingly.

Finally, we get to hospitals which are truly a category of their own. Hospitals have their own fee schedule known as the Hospital Outpatient Surgical Facility or HOSF fee schedule. (This fee schedule can be also be found using the link posted earlier.) However, the HOSF fee schedule, as the name indicates, is really only applicable to cases of outpatient surgery. Thus, if the previously cited example of a patient undergoing an X-ray took place in a hospital, the hospital would not be reimbursed for the X-ray pursuant to the HOSF unless the exam was in connection with outpatient surgery (such as pre-op testing).

So how is a hospital to be reimbursed for facility fees that are not associated with outpatient surgery? Callagy Law takes the position that hospitals are not subject to any fee schedule for (non-surgical) treatment provided to hospital outpatients. Such charges are subject to the hospital’s usual and customary rate. Insurance carriers tend to be in acknowledgment of this in the way that they reimburse emergency room visits, typically billed under one of the 9928X treatment codes. However, when it comes to other hospital treatment such as diagnostic testing, even when performed in conjunction with emergency room encounters, carriers tend to apply the TC rate of the physician’s fee schedule referred to earlier. Callagy Law has had an enormous amount of success in arbitration reversing these applications of the TC rate which are inapplicable to hospital outpatients.

It is important to remember that an insurance carrier’s determination as to how a claim should be paid is not necessarily correct. If you suspect that a claim was not paid correctly, or you simply are uncertain, be sure to reach out to Callagy Law, PC.

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.

Learn More About Callagy Law Here:

Facility Fees vs. Physician’s Fees #CallagyLaw, #Dobi, #Pip, #PipLitigation

Tuesday, February 2, 2016

New Rule Medical Providers Will Like | Callagy Law

DOBI HAS PROPOSED A NEW RULE AT NJAC 11:3-4.7B TO ESTABLISH UNIFORM APPEAL PROCEDURES THAT WE THINK MEDICAL PROVIDERS WILL LIKE

The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

On November 2, 2015, the New Jersey Department of Banking of Insurance (“Hereinafter “DOBI”) proposed amendments to certain current and pending regulations relating to the Internal Appeals procedures medical providers were required to comply with when faced with PIP denials. Under the old regulations and prior pending regulations, medical providers were required to strictly follow the specific procedures set forth in each insurance carrier’s (Hereinafter “Carrier”) Decision Point Review Plan in order in order to appeal.

As every medical provider, and every PIP attorney well knows, internal appeal procedures vary widely by both Carrier, and by type of appeal – meaning there is one set of procedures when appealing pre-service denials, such as precertification, and another set of procedures when appealing post-service denials, such as non-payment or under-payments. The only requirement placed upon the Carrier was that their internal appeals process must be published in its DOBI approved Decision Point Review Plan.

Also contained within these procedures are certain critical deadlines, which vary widely by Carrier. For example, one Carrier may require that any post service appeal be filed within 30 days of the denial, but require that any pre-service denial be appealed within ten days. Another Carrier may require pre-service denials to be appealed with 15 days but post service appeals be appealed within ten days. Keeping track of these deadlines on behalf of every Carrier can be quite complicated for the medical provider, yet it can become quite costly if they don’t.

Moreover, some Carriers impose a 2 level post-service appeal process while some require just one. Each level has their own unique timeline, as well. Further, some Carriers require that a first level appeal must be faxed to one number while second level appeals must be faxed to an entirely separate fax number. One Carrier even recently changed their requirements such that its first level appeal was required to be faxed to its 3^rd party administrator, but its 2^nd level appeal process required the medical provider to mail their appeal via certified mail only, with return receipt requested! Considering substantial supporting documentation is often required and included in a second level appeal, the size and cost of such a requirement imposed on the provider was quite burdensome.

Fortunately, in this most recent proposal, DOBI recognized that the varying internal appeals processes made it “complicated and burdensome” for providers to appeal and is now proposing to repeal and replace the current internal appeals process in its entirety.

In its place, DOBI is now proposing a uniform internal appeals process which must be adopted by all Carriers. [SEE IT HERE www.state.nj.us/dobi/proposed/prn09_207.pdf ]

The most significant changes for the medical provider in this latest proposal by DOBI include:

A uniform appeal form;

Carriers will be limited to one level of appeal only;

Uniform critical deadlines; pre-service appeals must be submitted within 30 days of the denial and Carriers must respond within 14 days, post service appeals must be submitted 45 days prior to initiating dispute resolution and Carriers will have 30 days to respond;

A clear definition of what constitutes a pre-service appeal and what constitutes a post-service appeal.

By and large, these changes are most welcome to the medical provider. Medical providers are well aware that, in addition to being complicated and burdensome, Carriers have repeatedly wielded the internal appeals process against the medical provider as a threshold weapon in arbitration. Compliance with a particular Carrier’s internal appeals process created a very fertile ground in the arbitration arena for a Carrier to argue that any variance, no matter how minor, forecloses the medical provider from ever being reimbursed for its services. The question of medical necessity is never reached. This defied the very purpose of internal appeals, which were instituted to provide a Carrier the opportunity to take a second look at a denial prior to being required to engage in costly arbitration or litigation.

Now however, should these proposed regulations be adopted, the internal appeals process will be uniform and simplified. Of course, arbitrators will continue to strictly enforce the regulations, but it appears the field will finally be leveled for the medical provider.

The Team at Callagy Law hopes the information in this article was helpful in either your personal or professional life. The legal world pertains to all walks of life and more specifically, various types of healthcare providers. Callagy Law, is a multidisciplinary law firm, headquartered in Paramus, NJ owned and operated by Sean Callagy. We are committed to providing legal representation and advice to our clients at additional law offices located across the United States. Please note that the information posted here should not be used as a legal argument of defense. If you find yourself needing legal advice pertaining to your unique situation, you can contact us at here. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

New Rule Medical Providers Will Like | Callagy Law #CallagyLaw, #Carriers, #Dobi, #MedicalProviders, #NewRule

Tuesday, January 26, 2016

Codes Not On ASC Fee Schedule Possibly Reimbursement | Callagy Law

Are CPT Codes not listed on the ASC Fee Schedule compensable in New Jersey PIP arbitration matters?

This issue of whether certain codes not listed on the ASC fee schedule are reimbursable to the ASC is currently a hotly contested one. The ASC fee schedule is located at N.J.A.C. 11:3-29.1(b), Appendix Exhibit 1, and is colloquially referred to as the ASC fee schedule. However, not all procedures performed at an ASC are listed on the ASC fee schedule. This often results in insurance carriers denying payment for such fees to these facilities.

To support their denials, the carriers refer to N.J.A.C. 11:3-29.5(a). On its face, that subsection clearly states that “codes that do not have an amount in the ASC facility fee column are not reimbursable when performed in an ASC.” Seemingly, it was DOBI’s intent to place certain codes on the ASC fee schedule that DOBI had affirmatively considered, and to also include those codes which DOBI had considered should not be performed at an ASC, but to leave those codes with no amount of reimbursement. However, for codes that do not appear on the ASC fee schedule, DOBI has not made such a consideration. Simply, DOBI has not considered such codes, and therefore, DOBI has not determined that such should not be performed at an ASC.

This firm takes the position that the ASCs should be entitled to UCR when hosting a procedure that is not listed at all on the ASC fee schedule. In accordance with N.J.A.C. 11:3-29.4(e) “the insurer’s limit of liability for any medical expense for any service or equipment not set forth in or not covered by the fee schedule shall be a reasonable amount considering the fee schedule amount for similar services or equipment in the region where the service or equipment was provided. … Only when there is no similar service in the fee schedule does the regulation state that “the insurer’s limit of liability for any medical expense benefit for any service or equipment not set forth in the fee schedule shall not exceed the usual, customary and reasonable fee.” Therefore, an ASC should be reimbursed at the usual, customary and reasonable (“UCR”) fee for codes that do not appear on the ASC fee schedule.

Several awards from arbitrators support our position, including the most recent award from DRP Nanci Stokes. In the matter of Gloucester Surgery Center a/s/o C.S. v. Plymouth Rock Assurance of New Jersey, NJ-1628906, DRP Stokes agreed with the ASC claimant’s position, whereby she found the following:

In this matter, I find that the claimant is entitled to reimbursement for CPT 24665… the overwhelming scheme of reimbursement as to an ASC is based upon Medicare’s determination and judgment relative to patient safety. This is specifically acknowledged by the Appellate Division in upholding the regulation at issue… The regulation specifically advises that CPT codes appearing on the Physician and ASC Fee Schedule …that do not have an amount in the ASC facility fee column are not reimbursable. The code at issue is not listed on the fee schedule. As such, there is no clear prohibition for reimbursement in the actual wording of the regulation regardless of the Department’s response relied upon by respondent. Accordingly, given Medicare’s allowance of CPT 24665 in an ASC and acknowledgment by the Department that Medicare’s determination adequately “ensures the safety of patients and the quality of services”, I find reimbursement is permitted.

As the code is not contained on the fee schedule, reimbursement is subject to a usual customary and reasonable analysis.

This firm completely agrees with DRP Stokes’ analysis, as well as similar rulings from some of her DRP brethren which also found that codes which are not listed on the ASC fees schedule are still reimbursable to ASCs.

This is still an evolving issue, but so far, the majority of DRPs have agreed with the Claimant’s position. As such, this firm is thrilled to be able to recover additional money for our ASC clients.

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.

Learn More About Callagy Law Here:

Codes Not On ASC Fee Schedule Possibly Reimbursement | Callagy Law #Asc, #CallagyLaw, #CommercialInsurance, #Dobi, #Drp, #MedicalRevenueRecovery, #Pip, #Reimbursments, #Wc

Tuesday, January 5, 2016

Can PPOs and PIP Coexist? | 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.

Health care providers are all too familiar with PPO agreements. While these contracts certainly provide a benefit to providers, they ultimately cut into their reimbursement on applicable claims. An interesting question, though, is what happens in an instance where a PPO contract conflicts with a PIP Medical Fee Schedule?

Typically, insurance carriers will apply a PIP fee schedule rate regardless of whether or not an applicable PPO contract exists, provided of course that the PPO rate exceeds the fee schedule rate. If the PIP fee schedule rate exceeds the PPO rate, then the insurer will likely apply the PPO rate. In other words, in determining whether to reimburse the provider according to the PPO or according to the PIP fee schedule, insurance carriers are likely to pay the lesser amount.

While this may seem like an unfair ploy by the insurance carriers to pay out as little as possible (it is), it is not without legal basis. PPO contracts have been deemed entirely enforceable and consistent with the PIP No-Fault scheme; however, it is well understood that parties cannot contract outside of the law as such would violate public policy. Thus, insurance carriers make the case that the PIP fee schedule is a government regulation capping the rate of PIP reimbursement, and a PPO contract exceeding that rate is not enforceable.

While there is merit to this insurance friendly argument, it is open to legal dispute. Health care providers can make the argument that the parties’ freedom to contract trumps the PIP fee schedule and, on occasion, PIP arbitrators will find in the Claimant’s favor on this issue. One has an even greater chance of achieving this result if the carrier applies a PPO rate to at least part of the claim. For example, in a case where the provider bills for multiple treatment codes and not all of these codes are found on the PIP fee schedule, the carrier will likely reimburse the fee schedule rate where applicable, and the PPO rate where the fee schedule is not applicable. In such a case, the provider can argue that the carrier has effectively acknowledged the applicability of the PPO to the claim, and the entire claim should therefore be governed by the PPO contract.

To be sure, some PPO contracts specifically state that reimbursement should be rendered pursuant to the lesser of the PPO rate or any applicable State fee schedule. In such cases, the provider has little if any chance of escaping the applicability of the PIP fee schedule given the express terms of the contract. However, the fact that the drafters of these contracts find it necessary to include such language gives credibility to the argument that, absent such language, the PPO rate should stand despite the existence of the PIP fee schedule.

As for whether receiving reimbursement pursuant to the PIP fee schedule rather than at a PPO rate warrants the filing of a PIP arbitration, this is not entirely clear as this issue more often than not is decided in the insurance carrier’s favor. However, it is certainly another issue to be mindful of for cases that are already facing arbitration for an entirely different issue. The more issues a provider can raise in a given case, the more likely they are to receive an award of reimbursement.

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 $175,000,000 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.

Learn More About Callagy Law Here:

Can PPOs and PIP Coexist? | Callagy Law #CallagyLaw, #DepartmentOfBankingAndInsurance, #Dobi, #Insurance, #Pip, #PipArbitration, #PipArbitrators, #PipFeeSchedule, #Ppo, #PpoContracts

Tuesday, December 29, 2015

A Closer Look into Bundling & PIP Regulations | Callagy Law

The Bucket 4 “Carve Out”

After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law and medical revenue recovery. Our mission is to answer any questions and give knowledge to many different aspects of these matters

This blog is a little bit “inside baseball,” in that it’s a hyper technical explanation look at a concept in the world of bundling. If you’re a PIP practitioner, however, or deal with ASCs and Hospitals, this is an important concept that could lead to a much larger amount of recovery/reimbursement for ASCs or Hospitals

When DOBI updated the PIP regulations (effective 1/4/13) the update included a new section on the “bundling” of outpatient surgical services. Specifically, N.J.A.C. 11:3-29.5(a)(1-8) and N.J.A.C. 11:3-29.5(b) (which incorporates (a)(1-8)) inform providers and carriers which services are considered “bundled” and are not separately reimbursable.

The code, in relevant part, reads as follows:

11:3-29.5 Outpatient surgical facility fees

ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fee include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including:

Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;

All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient’s care;

Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment;

Diagnostic and therapeutic items and service. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp, CMS-1504-FC, Exhibit AA), are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare are considered ancillary services that according to Medicare (see: https://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_

D1.pdf) are integral to surgical procedures and are not permitted to be reimbursed separately in a HOSF;

Administrative, recordkeeping, and housekeeping items and services;

Blood, blood plasma, platelets, etc.;

Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and

Implantable DME and prosthetics.

(b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The hospital outpatient surgical facility fee is the maximum that can be reimbursed for outpatient procedures performed in an HOSF. The hospital outpatient facility fees in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through (8) above.

(a)(1-8), which I’ll colloquially refer to as the “8 buckets,” essentially states that each bucket is included in the main surgical procedure that was performed in the ASC or Hospital on that particular date of service, and that the type of service described by that bucket is not separately reimbursable, since DOBI has already included reimbursement for such services in the price of the ain surgical code on the appropriate fee schedule.

There is a catch, however. N.J.A.C. 11:3-29.5(a)(4) states:

Diagnostic and therapeutic items and service.

Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare … are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC.

Appendix, Exhibit 7 indicates those services that, according to Medicare are considered ancillary services that according to Medicare… are integral to surgical procedures and are not permitted to be reimbursed separately in a HOSF;

Callagy Law’s PIP attorneys have been successful in arguing that bucket 4 actually is actually a “carve out,” and should be read and interpreted differently than the other 7 buckets. Our attorneys argue that bucket 4 requires a carrier to not simply state that all diagnostic and therapeutic items and services are automatically included in the main surgical procedure; rather, the carrier must first identify the diagnostic and therapeutic items and services and then proceed to the appropriate fee schedule (Exhibit 1 for ASCs, and Exhibit 7 for Hospitals) to determine whether those services are, in fact, bundled.

There is an entire column in Exhibit 7 (The Hospital Outpatient Surgical Facility Fee Schedule – “HOSF”), for example, titled “Packaged Item; No Separate Payment.” Our argument is that DOBI is directing providers and carriers to examine Exhibit 7 to see whether the particular diagnostic/therapeutic services being provided in a particular case are marked as bundled. (see screenshot of Exhibit 7 below)

Many diagnostic/therapeutic codes on the HOSF do have indicators in the column meaning that they are bundled, but many codes either have no indicator, or do not appear on the HOSF at all. In those cases, it is the position of the Callagy Law PIP attorneys that the diagnostic/therapeutic codes ARE entitled to separate reimbursement.

These diagnostic/therapeutic codes often add up to hundreds or thousands of dollars in a particular outpatient surgery, and so mastery of this concept can mean a great deal of additional recoverable money for a particular provider. This position has been successful with several arbitrators, and the wave of momentum for this argument only seems to be growing stronger.

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! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

A Closer Look into Bundling & PIP Regulations | Callagy Law #CallagyLaw, #Dobi, #Information, #LegalNews, #Pip, #Regulations

Tuesday, December 22, 2015

Reimbursement Under New Jersey PIP laws | Callagy Law

When does UCR (the usual, customary and reasonable amount) apply?

The purpose of this post is to help assist healthcare providers and the public with questions they have concerning topics related to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. The Callagy Law team is knowledgeable in all aspects of these sorts of legal matters and will frequently post topics in this field. We hope to have this article shine a light on many common questions.

Medical providers may wonder why a PIP insurance company pays less than the amount billed. For example, perhaps a north region doctor bills $200.00 for an office visit billed under CPT Code 99214. The PIP insurer reimbursed the doctor $125.71. Is a balance due? The general answer is no, and that is because a medical fee schedule governs the reimbursement for this treatment. Other times, however, there may not be a medical fee schedule at all. What is the standard of reimbursement in that instance?

To determine the proper amount due, a review of the New Jersey PIP reimbursement structure is in order. This discussion concerns reimbursement amounts, not whether PIP benefits apply in the first place. Other issues, such as medical necessity and causality, factor into such right to reimbursement.

As to the amounts due, it must be recognized the Department of Insurance and Banking (“DOBI”) has promulgated many medical fee schedules. These payment schedules cover a variety of types of medical providers, as well as a wide array of CPT Codes. A summary of these fee schedules may be found at http://www.state.nj.us/dobi/pipinfo/aicrapg.htm.

Therefore, the first step is to review the fee schedules listed on the DOBI website and see if the type of medical provider and CPT Code for the treatment is listed. Also, there are times a medical fee schedule may not apply. For example, if a trauma doctor provides trauma services and bills with a –TS modifier, the fee schedule amount will not apply, but rather, a UCR standard applies. N.J.A.C. 11:3-29.2 defines trauma services as follows:

“Trauma services” means the care provided in the Level I or Level II trauma hospital to patients whose arrival requires trauma center activation. It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activation or outpatient visits after a patient who has received trauma care is discharged from acute care.”

What is UCR? UCR is the usual, customary and reasonable amount due for treatment. How is UCR determined? The governing DOBI regulation, N.J.A.C. 11:3-29.4, provides the amount due will be that of a similar code on a medical fee schedule. If there is no similar code, UCR is determined by a process. First, the medical provider submits its customary bill. It is imperative the provider retain exemplar Explanation of Benefits showing the payment received from other payors. The PIP insurer may then determine the reasonableness of the fee by comparing its experiences with that provider and other providers in the region. The PIP carrier may also rely upon national databases of fees to determine the reasonableness of the bill for the provider’s geographic region.

Callagy Law handles many PIP arbitrations in which UCR is a significant issue. Our success generally depends upon the UCR proofs we are able to introduce at hearing. We implore our medical providers to retain copies of exemplar EOBs to show what PIP carriers are reimbursing them for treatment that is not subject to a medical fee schedule. It will help in our ability to obtain proper reimbursement at UCR if we have the supporting documents.

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! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Reimbursement Under New Jersey PIP laws | Callagy Law #CallagyLaw, #Cpt, #DepartmentOfInsuranceAndBanking, #Dobi, #MedicalProviders, #NjPipLaws, #PipLaws, #Reimbursement, #Ucr

Friday, June 12, 2015

Important Information Regarding DOBI

In order for hospital Emergency Room (ER) services to be reimbursed by No Fault (Personal Injury Protection or PIP) insurance carriers at the hospital’s usual and customary rates (UCR), the services must fall within the exemption, carved out by the Department of Banking & Insurance (DOBI) in its PIP regulations. That exemption states:

The non-physician facility fees in subchapter, Appendix, Exhibit 7 [the hospital outpatient fee schedule] shall not apply to services provided in hospital emergency rooms. The bills for these services shall use the modifier “-ER”.

Some Dispute Resolution Professionals (DRP’s), also known as arbitrators, interpret the word “shall” as being mandatory, that is, if the two initials “ER” do not appear after the CPT Codes on the bill, the Exhibit 7 HOSF rates apply, rather than the usually higher UCR rates. DOBI’s intent, these DRP’s reason, is that use of the modifier is not optional or permissive. If it were, DOBI would have used the word “could” or “can,” rather than the stricter “shall.” Ironically, these DRP’s undercut DOBI’s intent, rather than promote it.

Let me state at the outset, that it is the position of Callagy Law, supported by the commentary surrounding adoption of the exemption, that the modifier only applies to the surgical codes themselves, not any of the other codes growing out of an ER encounter, the purpose being to distinguish surgeries pursuant to ER treatment (reimbursable at UCR) from other outpatient surgeries (reimbursable at Exhibit 7 rates). Nevertheless, some DRP’s look to the modifier as necessary for all codes, not simply the surgical codes. In either event, they are incorrect.

The intent of the exemption is to make clear that in enacting the Hospital Outpatient Surgical Facility Fee Schedule DOBI did not intend to include ER treatment. Indeed, at times, ER treatment is considered outpatient treatment, and so, DOBI wanted to distinguish outpatient surgeries, akin to those performed at ambulatory surgery centers, which would be subject to the Exhibit 7 HOSF rates, with hospital ER services, which have no analogue. Accordingly, the great majority of DRP’s have determined that the absence of the modifier is not fatal to a claim for UCR, because the bill clearly uses other indicators that the treatment was ER treatment. Indeed, ER bills usually state on their face “Emergency Room” before the main ER evaluation code (9928X). The clinical records, moreover, are usually dispositive as to whether the encounter was an ER encounter or not. It is usually quite obvious from both the bills and the clinical records that treatment is ER treatment.

Yet, a small minority of DRP’s will ignore the obvious and pin their conclusion on the notion that DOBI “intended” the modifier to be mandatory. Let’s examine that.

Was DOBI’s intent with the exemption to create a new modifier? Was it somehow to strengthen use of modifiers in hospital billing practices, and, therefore, not using the modifier would deny a hospital what is usually a higher rate of reimbursement? Of course not. The intent of DOBI with the exemption was to allow UCR reimbursement of hospital ER charges, and use of the modifier seemed like a good way to convey to the carrier that the encounter grew out of the ER. Otherwise, you would think DOBI would have stated consequences for failure to use the modifier, but it doesn’t. If by all indications the services were part of ER treatment, but, because of failure to use the modifier, the hospital loses the benefit of the exemption, DOBI’s intent to reimburse the services at UCR is clearly undermined.

How do you reconcile use of the word “shall” with the idea that the modifier’s use is not mandatory? Easy. I read “shall” in this instance as no different from the word “will.” It is instructive. Use the modifier ER to convey to the carrier that the services are ER services. If, however, it is otherwise clear that the services were ER services, the same end is achieved.

To deny hospitals the benefit of the exemption because the ER modifier was not used, when all indications from the bill and clinical records is that the services were the result of an ER encounter, does not foster DOBI’s intent—It grossly undermines it.

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