New Jersey PIP Arbitration Lawyer for treating medical providers
New Jersey PIP Arbitration Lawyer - In New Jersey PIP Arbitrations are the mechanism set up by the New Jersey Department of Insurance to resolve disputes between Medical Providers and Automobile Insurance Companies. If you are a medical provider and have unpaid medical bills call today to speak with an experienced PIP Arbitration Lawyer. Call to have a free initial consultation with a PIP Arbitration Attorney. The Arbitration Proceedings are decided by Forthright Solutions the appointed arbitrators of the disputes. These proceedings are governed by Rules set up by Forthright as approved by the Department of Insurance and Banking.
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Steven P. Lombardi, Esq.
PROCESS TO OBTAIN PAYMENT OF MEDICAL BILLS
Speak with a PIP Arbitration Lawyer for your New Jersey PIP Claim. All medical treatment must be PreCertified by the PIP Insurer to be payable without dispute. If the Insurer denies treatment after a PreCertification Request it is still payable if later found to be medically necessary. Failure to Pre-certify results in a 50 % penalty even if the treatment is found to be medically necessary. All billing must be submitted using Current Procedure Terminology Codes (CPT). Once a bill is submitted to the Insurer they will consider payment for same and issue an Explanation of Benefits (EOB) letter. If denied due to medical necessity, usually as a result of a Peer Review, an Arbitration is required to compel payment. To initiate the Arbitration Process a Petition needs to be sent to Forthright with a filing fee of $225. The Petition must be served by way of Certified Mail to the correct address maintained by Forthright for each Insurance Company licensed to write Automobile Insurance in New Jersey. The Medical Provider may only seek payment by way of an Assignment of Benefits this must be also provided at the time of the filing. Once the Petition is filed a Dispute Resolution Professional (DRP) is appointed. Thereafter, if the dispute is for more than $1,000 as per the Fee Schedule, a Hearing Date is set up. The parties called Petitioner (Medical Provider) and Respondent (Insurance Company) then both provide a statement as to their respective positions. Thereafter a hearing is held and a decision made by the Arbitrator. Once a decision is made there is a limited right to appeal the Arbitrator's Ruling in the New Jersey Superior Court.
COMMON DEFENSES TO ALLOW AN INSURER TO ESCAPE PAYING MEDICAL TREATEMENT OR OTHER PIP BENEFITS - New Jersey PIP Arbitration Lawyer
An insured must cooperate with the Insurance Company and provide a Statment Under Oath, which is usually an informal, but recorded, oral statement to the Insurer's Investigator as to the issues related to coverage. Specifically the Insurers will want to know who resided with the injured party at the time of the accident if they are not a policy named insured. The Insurer will also want information as to the accident and injuries suffered. The Insurance Company will also want the injured person to attend what the insurers call an Independent Medical Examination (IME), which is anything but independent as the examination is set up with physicians paid by the insurance companies to determine whether or not to cut off treatment to the injured insured. If an insured fails to attend these proceedings a full denial of benefits will occur.
The other way the Insurance Companies deny payment for medical treatment is by claiming that the treatment is not Medically Necessary. This is done even without a physical examination of the injured insured, by way of Peer Reviews of the Medical Records alone called a Decision Point Review. The records must be reviewed by a physician or chiropractor or other medical provider with an identical qualification as the prescribing doctor to be a valid review.
APPEALS OF DENIALS DUE TO MEDICAL NECESSITY NOW REQUIRED
A Medical Provider will need to file an appeal for any denial of treatment as a prerequisite to filing any Arbitration with Forthright. If the medical provider fails to first file the Internal Appeal the Petition filed with Forthright can be dismissed.
CARE PATH PROTOCOLS FOR CERTAIN INJURIES MUST BE FOLLOWED
All medical treatment must follow the Protocols of the Care Paths established by the Regulations. These are established firmly for back and neck injuries. No Care Paths are set for injuries to other parts of the body. For the treatment Protocols see links below.
PRECERTIFICATION OF MEDICAL TREATMENT
In order to obtain Medical Treatment reinbursement a provider must Pre-Certify the treatment to be rendered through the insurer's process. Each insurer has its own fax number and precertification department. A record of all fax transmittals and documents transmitted should be maintained by the provider so that there can be no question at a later date as to what was sent to the Insurer and the date of transmittal. All fax confirmations must be maintained in order to prevail at Arbitration. All Providers must follow the Medical Protocols set forth in the Regulations. See Precertification Procedures Below. See here for a full list of Insurance Carriers and their PIP Contact Information. (PLEASE NOTE THESE ARE SUBJECT TO CHANGE AND INDEPENDENT CONFIRMATION WITH THE INSURANCE COMPANY MUST BE MADE AT THE TIME OF PRECERTIFICATION)
PENALTY/CO-PAYMENTS AND THE DECISION POINT REVIEW PROCESS ALSO NETWORK PROVIDERS MUST BE USED TO AVOID PENALTIES
If a request for Decision Point Review or Precertification is not submitted as required, or if clinically supported findings that support the request are not supplied, payment of your bills will be subject to a penalty co-payment of fifty (50) percent even if the services are determined to be medically necessary, causally related and reasonable. This co-payment is in addition to any deductible or co-payment under the Personal Injury Protection coverage. If you do not utilize a network provider/facility to obtain those services, tests or equipment listed in the voluntary utilization review program section set forth above, payment for those services rendered will result in a co-payment of thirty (30) percent (in addition to any deductible or co-payment that applies under the policy) for medically necessary, causally related and reasonable treatment, diagnostic tests and durable medical equipment. Keep in mind that treatment which is not medically necessary, causally related and/or reasonable is not reimbursable under the terms of the policy.
OVERVIEW OF NEW JERSEY PIP BENEFITS
If you have been injured in an Automobile Accident your Insurance Company provides certain Medical and other Benefits in the Policy called Personal Injury Protection (PIP) Benefits. Typically these benefits are for $250,000 in Medical Treatment coverage. Recent Legislation however allows Consumers to choose a lower coverage option reducing the Policy Benefits to as low as $15,000 or even zero coverage with some extended benefits for catastrophic injury. A deductible and Copayment also apply to the PIP Benefits. Typically a $250 dedcutible applies with a 20% copayment on the first $5,000 of billing is applicable, meaning an insured will be responsible for $ 1,250 of the medical bills as this limited coverage is available for the initial bills up to the first $ 5,250 of billed treatment. Recent Legislation also allows for higher deductibles for PIP Insurance exempting up to the first $5,000. There are other benefits under these Policy Provisions for Income Continuation, Essential Service Benefits and Death and Funeral Benefits as well.
EXPEDITED ARBITRATION PROCEDURE
The proceedure to obtain medical treatment is as follows:
Pursuant to N.J.A.C. 11:3-5.4(b) 6, an injured person or his/her health care provider may seek an expedited MRO determination of the medical necessity of future treatment or testing. If an
insurer denies approval for medical treatment or testing as not medically necessary and the treatment or testing has not occurred, then the injured person or his/her health care provider may request
an expedited determination of medical necessity by a Medical Review Organization (“MRO”). The request shall be made by filing with Forthright a Demand for Arbitration, an Expedited Medical
Necessity Determination Request Form, indexed copies of unredacted medical records and the fee payment set forth in Rule F-5. These documents must be served upon all other parties.
Pursuant to N.J.A.C. 11:3-5.4(b) 6, no DRP will be assigned and no attorney’s fees may be claimed for requesting an expedited MRO determination.
The insurer may submit to Forthright an Expedited Medical Necessity Determination Response Form and any additional unredacted medical records. Any additional medical records must be received by Forthright within 15 days of the date Forthright has acknowledged receipt of the request. Copies of these documents must be served upon all other parties. Upon expiration of the 15 day period above, Forthright will transmit the request, any response and the parties’ documents to the MRO. No further documents or requests will be submitted unless requested by the MRO. In the event the MRO requests additional documents, the parties shall have ten (10) days from the date of the request to submit the documents. When Forthright receives the report from the MRO regarding medical necessity, it will transmit copies to all parties. If the MRO determination resolves the parties’ dispute, then the parties will so advise Forthright, which shall administratively dismiss the case. If the MRO concludes that the medical treatment or testing in issue is not medically necessary, then the injured person or health care provider may proceed with the arbitration. The determination of the MRO health care consultant shall be presumed to be correct by the DRP, which presumption may be rebutted by a preponderance of the evidence. Should the DRP find that the decision of the health care consultant is not correct, the reasons supporting that finding shall be set forth in the DRP’s decision. All other issues raised by the parties will be decided by the DRP at the time of the arbitration hearing.
WE HELP MEDICAL PROVIDERS GET PAID CALL NOW FOR A FREE NJ PIP LAWYER CONSULTATION
We here at the Lombardi Law Firm represent Physicians, Chiropractors, Acupuncturists, MRI / X Ray Facilities, Pain Management Facilities, Physical Therapy Facilities and other medical providers to compel payment for their services through the filing of PIP Arbitration Claims. The Rules and Regulations governing the filing of PIP Arbitrations have recently changed. The new Rules became effective in February 2013 and some of the provisions of those new Regulations are to become effective in September of 2013.
PIP RULE CHANGES FOR 2013
A summary of the Rule changes are as follows.
1. In Person Hearings are no longer available for claims less than $1,000 as per the Fee Schedule Amount.
2. Various Pain Management Out Patient facility charges have been incorporated into the Fee Schedule.
3. Acupuncture procedures are now incorporated into the daily cap as applicable to chiropractic and physical therapy treatments now set at $105 per day. See list of Procedures incorporated into daily cap here.
4. A Standardized Appeal Form will be required to be used (effective September 2013)
See a Summary of the Entire Rule Changes Here
See New Fee Schedule Here ( Effective January 5, 2013)
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Steven P. Lombardi
374 Millburn Ave Suite 301
Millburn, NJ 07041
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MONMOUTH COUNTY OFFICE
Atlantic Highlands NJ 07716
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