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.
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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