Sean Callagy - Attorney and Entrepreneur: healthcare law services

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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Friday, November 13, 2015

Why Is an Assignment of Benefits So Important? | 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.

When it comes to pursuing PIP/No-Fault claims, also known as Motor Vehicle Accident (MVA) claims, obtaining an Assignment of Benefits (AOB) from a patient is absolutely essential. This is also true of Commercial Insurance (CI) claims. An AOB is a document by which a patient transfers their rights under their insurance policy to the medical provider who is treating them. Why is this so important?

A medical provider in the context of PIP or CI has no contractual relationship with the insurance carrier. If a patient sees a medical provider and that provider, with nothing else, bills the patient’s carrier, there is nothing binding the carrier to pay the medical provider. The AOB places the medical provider in the shoes of the patient as far as the patient’s insurance policy is concerned, enabling the provider to be paid directly. If you are a health care provider, seeing a PIP or CI patient, and wish to be paid directly for covered services from an insurer, you must obtain an executed AOB.

You might be wondering why I do not include Workers Compensation (WC) claims along with PIP and CI claims in terms of the necessity of an AOB. AOB’s are not critical to WC claims. The reason for this is that the patient does not have an insurance policy in the WC context. Their employer does. So, there is no insurance policy with which the patient has direct involvement. What is critical is the authorization. The authorization is what creates the legal relationship between the carrier and the medical provider.

In short, obtaining a properly executed AOB should always be on the top of any medical provider’s list when rendering services to a PIP or CI patient.