Sean Callagy - Attorney and Entrepreneur: legal news

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Friday, April 1, 2016

Decision Point Review Plans and Their Significance

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.

Learn More About Callagy Law Here:

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

Monday, January 18, 2016

Upcoming Shortage of Physicians | Callagy Law

Difficulties Facing the American Healthcare System – What You Need To Know!

There are many difficulties facing the American healthcare system, but perhaps chief among them is a possible shortage of physicians. The Association of American Medical Colleges (AAMC) predicts that an approximate shortage of 90,000 – 130,000 physicians will occur in the US by the year 2025. There are many factors contributing to this problem, including inadequate enrollment in medical schools.

Many new allopathic (M.D. granting) and osteopathic (D.O. granting) medical schools have been established in recent years, with overall medical school enrollment expected to increase by 30% by 2019. New Jersey has recently started Cooper Medical School of Rowan University and Seton Hall School of Medicine to help meet the health care needs and many other states are following suit.

While increasing the number of medical schools would help to alleviate this shortage, perhaps a more important and overlooked issue is reduction in the fund of residency positions. A residency is a multi-year education program medical school graduates must complete before they can become practicing physicians or surgeons. In 1997, Congress capped the number of Medicare-supported residency positions. In other words, even if we add medical school graduates by increasing the number of medical schools, we will not add to the number of practicing physicians unless we also add to the number of residency training programs. A bill was introduced that would increase residency positions in 2012, but Congress has yet to act on the bill.

The AAMC urges all Americans to rally for support of this bill, and while it will not entirely fix the projected physician shortage, it seems to be a step in the right direction.

Sources

http://www.ama-assn.org/ama/pub/news/news/2015/2015-03-05-ama-applauds-congress-modernize-graduate-medical-education.page

https://www.aamc.org/newsroom/newsreleases/305476/120928.html

https://www.congress.gov/bill/112th-congress/house-bill/6562

https://www.aamc.org/newsroom/newsreleases/431036/20150430.html

Photo Credit: www.vox.com

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:

Upcoming Shortage of Physicians | Callagy Law #Allopathic, #CallagyLaw, #CommercialInsurance, #LegalNews, #MedicalRevenueRecovery, #MedicalSchools, #Osteopathic, #PhysicianShortage, #Pip, #Problems, #WorkersCompensation

Thursday, January 14, 2016

Section 20 Settlements

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.

Section 20 Settlements

According to N.J.S.A. 34:15-20, the parties to a workers’ compensation claim petition may settle the claim where (1) jurisdiction, liability, causality and/or dependency are disputed; (2) the parties wish to resolve the claim with a lump sum settlement; (3) the parties consent to the settlement; (4) the parties are represented by Counsel; and (5) a judge of compensation determines that the settlement is fair and just under the circumstances. Notably, once the settlement is approved, it shall have the force and effect of a dismissal of the claim petition and shall be binding on the employee and employee’s dependants. Id. Such settlements are commonly referred to as “Section 20 Settlements” based on N.J.S.A. 34:15-20. In relevant part, N.J.S.A. 34:15-20 states:

34:15-20. Dispute; submission to division; order approving settlement.

…

After a petition for compensation or dependency claims has been filed, seeking compensation by reason of accident, injury or occupational disease of any employee, and when the petitioner is represented by an attorney of the State of New Jersey, and when it shall appear that the issue or issues involve the question of jurisdiction, liability, causal relationship or dependency of the petitioner under this chapter, and the petitioner and the respondent are desirous of entering into a lump-sum settlement of the controversy, a judge of compensation may with the consent of the parties, after considering the testimony of the petitioner and other witnesses, together with any stipulation of the parties, and after such judge of compensation has determined that such settlement is fair and just under all the circumstances, enter “an order approving settlement.” Such settlement, when so approved, notwithstanding any other provisions of this chapter, shall have the force and effect of a dismissal of the claim petition and shall be final and conclusive upon the employee and the employee’s dependents, and shall be a complete surrender of any right to compensation or other benefits arising out of such claim under the statute.

Parties should be aware of the availability of Section 20 settlements when defending/pursuing workers’ compensation claims as an option to avoid protracted litigation. Indeed, Section 20 Settlements are particularly appealing where the costs of defending against or pursing a claim are not sensible in light of the value claim. However, when entering into a Section 20 settlement, the parties should be mindful of the fact that such a settlement will likely bar any subsequent claims by the petitioner and such employee’s dependants.

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:

Section 20 Settlements #CallagyLaw, #Law, #LegalFacts, #LegalNews, #MustRead, #Section20, #Section20Settlements, #WorkersComp, #WorkersCompensation

Tuesday, January 12, 2016

MAKING NO-FAULT NO PROBLEM | Callagy Law

A closer look into No-Fault, PIP and other important information

After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Do you have questions pertaining to reimbursement? Do you know what to do if problems arise? With articles written by Callagy Law’s law team, this blog will focus on many common questions and concerns surrounding legal matters which can arise in the field of healthcare law.

Car accidents can be overwhelming, one minute you’re on your way to work, the next minute you’re sorting through medical bills and trying to determine if you have enough insurance coverage for accident related injuries. This is why an understanding of medical benefit coverage under your New Jersey automobile insurance policy is crucial.

In the New Jersey No- Fault System, a patient’s medical claims are paid under the Patient’s First Party Policy, even if the motor vehicle collision is the patient’s own fault. All personal car insurance policies in New Jersey must contain No Fault coverage. These No- Fault Benefits are known as Personal Injury Protection or “PIP.”

The benefit of the PIP System is that the determination of liability has no bearing on the Insurance Company’s responsibility to pay the insured’s medical bills, which allows for a medical provider to receive payment prior to the underlying issue of liability being resolved. Basically, this system allows a patient to receive their necessary treatment, and a doctor to receive prompt payment.

As payment is made under the patient’s own policy, it is important that owners of private vehicles make prudent decisions when choosing their PIP Policy Coverage Limits.

The State of New Jersey allows for the election of PIP coverage in lesser amounts ($150,000.00, $75,000.00, $50,000.00 or $ 15,000.00).

Ideally, every patient would be insured under a $250,000.00 PIP Policy, meaning a patient’s medical bills would be covered up to a total of $250,000.00.

However, a patient may be enticed to select a Basic Policy, which provides only limited coverage in the amount of $15,000.00. While a limited policy may seem great at first glance, as the premiums are lower, if a patient is in a significant collision, their policy may be quickly exhausted leaving the patient on the hook for thousands in medical bills.

For example, subsequent to a motor vehicle collision, a patient may be transported to a Hospital for Emergency Room Treatment; thereafter, an extended period of chiropractic care for neck/back injuries will be recommended; and the patient may be further referred for MRIs, EMGs, pain management care and even surgery, which will easily exceed $15,000.00.

Additionally, in New Jersey, an automobile owner may choose a Health Insurance Primary Policy wherein a motor owner designates his/her health insurance policy is primary for a reduced premium.

When a patient is insured under a Health Insurance Primary policy it very important that the Medical Provider bill the Patient’s Health Insurance Provider first. After a denial is received from the Health Insurance Carrier, the Medical Provider must submit the Health Insurance Denial as well as the Providers bill to the patient’s PIP Carrier for payment.

In sum, it is important for a patient to research their options and be aware of the consequence that may follow when selecting PIP coverage for a reduced amount at a lower premium.

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:

MAKING NO-FAULT NO PROBLEM | Callagy Law #AutoAccidents, #AutomobileAccidents, #CallagyLaw, #Insurance, #InsuranceInformation, #LawOfficeOfSeanRCallagy, #LegalFacts, #LegalNews, #MotorVehicleAccident, #NjLawFirm, #NjNoFault, #NoFault, #ParamusLawFirm, #SeanCallagy, #SeanRCallagy

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

Monday, November 23, 2015

Law and Entrepreneurship TV - Episode #22, #‎AskSeanCallagy‬

Exponential Growth and the Trajectory of Your Success

Callagy Law and Entrepreneurship Library – TV is an original series from Sean Callagy, President and Founder of Callagy Law; to help the general public with every day legal questions and information. For more information about Sean Callagy, Callagy Law, or any questions you have, please email scallagy@callagylaw.com

If you’d like to have your legal questions answered on the show, email Sean: scallagy@callagylaw.com

See more here: www.callagylaw.com/blog

In this article / video, Sean Callagy will focus on topics to help people better their legal knowledge of vital information. Clients often come to Sean Callagy’s team with questions about their businesses, ranging from contracts, disputes, and other common legal issues in the business and entrepreneurial world. Our mission is to answer any legal questions and provide information to anyone who may need it. If you have questions about any of the content you see or to have your questions answered on an upcoming show by Sean, please email your questions directly to him by clicking here.

Law and Entrepreneurship TV - Episode #22, #‎AskSeanCallagy‬ #BusinessCoaching, #BusinessLaw, #CallagyLaw, #Coaching, #Entrepreneur, #Entrepreneurship, #FamilyLaw, #GoalSetting, #LawFunding, #LegalNews, #Litigation, #MajorMedical, #MedicalRevenueRecovery, #Motivation, #SeanCallagy, #SeanRCallagy, #Success

Tuesday, November 17, 2015

Law and Entrepreneurship TV - Episode #18, #‎AskSeanCallagy‬

Exponential Growth and the Trajectory of Your Success

If you’d like to have your legal questions answered on the show, email Sean: scallagy@callagylaw.com

See more here: www.callagylaw.com/blog

Law and Entrepreneurship TV - Episode #18, #‎AskSeanCallagy‬ #BusinessCoaching, #CallagyLaw, #Coaching, #Entrepreneur, #Entrepreneurship, #GoalSetting, #LegalNews, #LifeCoaching, #Motivation, #SeanCallagy, #SeanRCallagy

Thursday, November 12, 2015

Callagy Law Library TV - Episode #15, #‎AskSeanCallagy‬

Exponential Growth and the Trajectory of Your Success

Callagy Law Library – TV is an original series from Sean Callagy, President and Founder of Callagy Law; to help the general public with every day legal questions and information. For more information about Sean Callagy, Callagy Law, or any questions you have, please email scallagy@callagylaw.com

If you’d like to have your legal questions answered on the show, email Sean: scallagy@callagylaw.com

See more here: www.callagylaw.com/blog

In this article / video, Sean Callagy will focus on topics to help people better their legal knowledge of vital information. Clients often come to Sean Callagy’s team with questions about their businesses, ranging from contracts, disputes, and other common legal issues in the business world. Our mission is to answer any legal questions and provide information to anyone who may need it. If you have questions about any of the content you see or to have your questions answered on an upcoming show by Sean, please email your questions directly to him by clicking here.

Callagy Law Library TV - Episode #15, #‎AskSeanCallagy‬ #Askseancallagy, #CallagyLaw, #LawOfficeOfSeanRCallagy, #LegalNews, #Motivation, #NjLawFirm, #ParamusLawFirm, #SeanCallagy, #SeanRCallagy, #Success

Wednesday, November 11, 2015

NEW! FREE! PLEASE SHARE! Why Not Double Your Income Part II - How?!

Today’s Why Not Huddle with Sean Callagy

Why Not with Sean Callagy Episode 14 – November 11, 2015

Dear Kindred Spirits:

Good morning!!!!!

If you haven’t checked out our Why Not Talk Episode 2 with Rey Rostami, you will be missing a how to quadruple your sales appointments, along with a story to give you certainty on how to overcome huge challenges as Rey went from gang member to award winning sales man and trainer.

Yesterday, we discussed the idea of how you feel about doubling your income, and the practical impact of those thoughts and feelings on your income.

Some people felt teased by Why Not Huddle 13 as we didn’t discuss any “how to”.

Believe it or not, the “how to” is always far easier than remaining “At Cause” in “Zone Action”.

Okay, so, let’s get right to it.

If you are working for a salary, you have two choices:

1. Start a separate company on your own: or

2. Figure out how to add five to ten times the value you are currently creating for your company.

If you are a sales person or business owner, then you double your income by doubling your sales. This is far easier than most people think.

All sales increases are reverse engineered. It starts with doubling the number of your meetings. If you double the number of meetings, and increase your yes rate, or even simply maintain it, then if you work on commission, you will obviously have doubled your income.

So, if it’s that easy, WHY NOT follow that system? Well, we come right back to the reason the Why Not Huddle exists: to keep people “AT CAUSE IN ZONE ACTION”.

Most people simply don’t operate in Zone Action virtually at all. Simply changing this fact will change everything.

What is Zone Action in Sales?

1. Engaging in direct and controlled actions to create meetings; and

2. Engaging in direct and controlled actions to have clients say yes to your product or services that they need.

This doesn’t happen. Only the top small percentage of sales people who are following a Zone Action system and living At Cause do this.

AND, if they care to, are very capable of doubling their income.

Remember, I went from broke to a beach house in one year. This is how it works for everyone!

Please share this on your Facebook Timeline or on LinkedIn, along with today’s Why Not Video!

Why Not?

In Your Service,

Sean Callagy

Please subscribe on YouTube and spread the word.

You can see all of our WHY NOT – HUDDLE videos by clicking here and subscribing! If you have questions about any of the content you see or to have your questions answered on an upcoming show by Sean, please email your questions directly to him by clicking here.

The Daily Why Not Huddle is for you if you want more money, time, or fulfillment. The Why Not Huddle with business coaching expert, successful entrepreneur, and attorney Sean Callagy provide the essential daily ingredients for you to create and achieve your destiny.

NEW! FREE! PLEASE SHARE! Why Not Double Your Income Part II - How?! #CallagyCoaching, #CallagyLaw, #LegalNews, #Motivation, #NjLawFirm, #SeanCallagy, #SeanRCallagy, #Success, #WhyNot, #Youtube

Tuesday, November 10, 2015

Callagy Law Library TV - Episode #12, #‎AskSeanCallagy‬

If you’d like to have your legal questions answered on the show, email Sean: scallagy@callagylaw.com

See more here: www.callagylaw.com/blog

In this article / video, Sean Callagy will focus on topics to help people better their legal knowledge of vital information. Clients often come to Sean Callagy’s team with questions about their businesses, ranging from contracts, disputes, and other common legal issues in the business world. Our mission is to answer any legal questions and provide information to anyone who may need it. If you have questions about any of the content you see or to have your questions answered on an upcoming show by Sean, please email your questions directly to him by clicking here.

Callagy Law Library TV - Episode #12, #‎AskSeanCallagy‬ #AskSeanCallagy, #BusinessLitigation, #CallagyCoaching, #CallagyLaw, #GoalSetting, #LawLibraryTv, #LawOfficeOfSeanRCallagy, #LegalFacts, #LegalNews, #LegalQuestions, #Litigation, #NjLawFirm, #ParamusLawFirm, #SeanCallagy, #SeanRCallagy, #Youtube

Tuesday, October 27, 2015

Beware of the Finality Clause of a PPO Agreement

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.

Under the New Jersey No-Fault laws, medical providers who treat patients injured in motor vehicle accidents can arbitrate PIP claims against No-Fault insurance carriers. Some of these medical providers have entered into PPO agreements with various insurance companies. These “preferred provider” contracts govern how the provider will be paid by the carrier. Generally speaking, the provider is willing to accept a lower reimbursement amount in exchange for faster reimbursement as well as inclusion in a network of preferred medical providers.

Unfortunately, medical providers may not be aware of some of the pitfalls in a PPO contract. One issue that can be troubling in a New Jersey PIP arbitration is what is commonly referred to as the “finality clause.” The “finality clause” is a provision in the PPO contract that typically states that the medical provider will “accept” whatever amount the insurance company pays, unless they dispute the amount in a certain period of time. We often see the dispute period as ninety-days. A typical finality provision reads something like the following:

“Neither the Medical Provider nor the Payor may dispute the amount billed or paid more than ninety (90) days after payment.”

“The payment made under this Agreement may not be disputed after ninety (90) days from payment.”

For example, suppose a provider provides a medically necessary service to a PIP patient, and then bills an insurer $1,000.00 and is entitled to that amount under the New Jersey PIP regulations. The insurer responds by issuing a payment in the amount of $500.00. Let’s say the PPO contract provides for payment at 90% of the amount billed. In such case, the provider should have been reimbursed $900.00. Let’s also say the provider does not dispute the payment, in the form of an official appeal, until six months later when it wishes to seek redress. Let’s also say that the carrier denies any additional payment as a result of the appeal. The provider then files a Demand for arbitration in New Jersey. The insurer will likely raise the finality provision as a defense against having to pay any additional money, and will argue that the provider may no longer dispute the amount paid, having waited beyond the contractual period to appeal. This defense may prove successful for the insurer.

The provider should pay attention to the provisions of its PPO contracts. If a finality clause is contained in the contract, the provider should file its objection to the amount paid in a timely basis and in accordance with any other requirements in the agreement. It is advisable to limit the defenses that may be prevent a hearing on the merits of the provider’s right to redress.

We do have arguments to make to overcome the defense of a finality provision, but the most effective arsenal we can have to prevail is an appeal (with proof of delivery) demonstrating the medical provider indeed did timely dispute the payment in accordance with the PPO contract.

Learn More About Callagy Law Here:

Beware of the Finality Clause of a PPO Agreement #CallagyLaw, #FinalityClause, #LegalFacts, #LegalNews, #Ppo