Sean Callagy - Attorney and Entrepreneur: wc

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?

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.

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.

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Wednesday, November 4, 2015

Don’t Let Your Claims Expire: Statute of Limitations on Workers Compensation Medical Provider Claims

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.

In 2012, N.J.S.A. 34:15-15 was amended to give the Workers Compensation Court exclusive jurisdiction over medical provider claims. Prior to 2012, it was clear that the statute of limitations for a medical provider’s claim was the six-year statute set forth in N.J.S.A. 2A:14-1, which applies to all actions of a contractual nature, express or implied, and all actions to recover on an account. Although it is unclear whether a two-year statute of limitation applies to medical provider claims filed after 2012, medical provider claims arising from events prior to the establishment of exclusive jurisdiction should carry a six-year period. The Appellate Division clearly held that the six-year period applied to the medical provider’s claim in Medical Diagnostic Assocs. v. Hawryluk, 317 N.J. Super. 338, 349 (App. Div. 1998), certif. denied, 160 N.J. 89 (1999), stating:

Finally, we deem it appropriate to discuss the statute of limitations issue in the event the Division determines that the employee’s claim is not compensable. Plaintiff asserts that if medical providers are not allowed to bring suit in the Law Division, there is the potential that their claims will be barred by the statute of limitations. The statute of limitations is six years. See N.J.S.A. 2A:14-1. We note that there is no statutory provision tolling the statute of limitations on the medical provider’s claim while an employee’s claim is pending in the Division. We are satisfied, however, that if a medical provider’s suit is transferred to the Division, as we hold today, the complaint will have been timely filed. In future cases in which the medical provider proceeds directly in the Division the statute of limitations will be tolled during the period that the matter is pending in the Division. Ibid. (emphasis added)

In Hawryluk, the Appellate Division transferred the medical provider’s claim to the Division and held that the statute of limitations for the claim was six years. In Univ. of Mass. Mem’l Med. Ctr. v. Christodoulou, 180 N.J. 334, 345 (2004), the Supreme Court overruled Hawryluk on the necessity of transferring the medical provider’s claim to the Division for a judgment of non-compensability before a Superior Court action could be filed, but did not alter its holding with respect to the statute of limitations. Although the Legislature subsequently amended N.J.S.A 34:15-15 to give exclusive jurisdiction to the Division for medical provider claims, eliminating the Superior Court option, there is no reason to suggest that the Legislature also intended to change the statute of limitations. The statute remains six years, as it does in all collection cases of a contractual or quasi-contractual nature.

A two-year statute would unfairly prejudice medical providers who rendered services to injured employees and were entitled to rely on the six-year statute in managing collection activity on their unpaid accounts. It would deprive medical providers of their property interests without any basis in a duly enacted statute. It would also unjustly enrich insurance carriers who collected premiums to pay for patients’ medical bills, then deliberately underpay for services rendered to those patients.

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 Callagy Law has some great reviews and is working hard to be a leader in multiple fields of the legal profession.