What is “Usual, Reasonable and Customary” When There is No Fee Schedule for Healthcare Providers?
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.
Many may not be entirely aware, but the New Jersey Workers’ Compensation courts provide a forum for healthcare providers to challenge inadequate reimbursements from workers’ compensation insurance carriers where the underlying claim is for a patient injured within the course of their employment. When a healthcare provider files its application with the Workers’ Compensation court, it seeks to obtain additional payment for treatment that was authorized and provided to the injured worker. However, there is no fee schedule in place for workers’ compensation healthcare providers. In these medical provider claims, the issue typically is not a contractual one; instead, the issue often is what constitutes the usual, customary and reasonable charges (or “UCR”) and the payment that should be made for a given medical service rendered to an injured worker. When determining UCR, it is appropriate to look at a myriad of factors including but not limited to paid fees and all payments made to the carrier by commercial and non-commercial carriers.
The New Jersey Workers’ Compensation Court recently issued an opinion in the matter of Burn Surgeons of St. Barnabas v. Shop Rite concerning the payment of medical treatment in the context of a New Jersey workers compensation case. In adopting the reasoning in Coalition for Quality Healthcare v. New Jersey Department of Banking and Insurance, 358 N. J. Super. 123 (App. Div. 2003), Judge Dietrich in Burn Surgeons accepted that it is appropriate to use paid fees rather than billed fees to make a determination as to the usual and prevailing fees in billing. Judge Dietrich also accepted that there is a “balancing act between the attempts to contain costs while providing for a fair level of reimbursement for services rendered.”
Further, according to Task Force Report on Medical Provider Claims submitted on November 5, 2010, there are many factors that a Judge may consider in determining the UCR of a given medical treatment and the appropriate payment for said treatment. While the following is not exhaustive, the Report provided that considering the following can act as a useful guide for the parties to consider in presenting proofs and likewise, to the jurist, in deciding a case: the fees customarily paid for like services within the same community; the fees paid to the same physician or medical provider by other payers for like treatment; the fees billed and the accepted payments for such bills by a given provider; the disparity in payments accepted from different sources (i.e. Medicare vs. PIP and commercial carriers); using commercial and/or private databases such as Ingenix’s Prevailing Healthcare Charges System (“PHCS”); the Medical Data Resource (“MDR”) database, and; Wasserman’s Physician Fee Reference (“PFR”) database to name a few.
As also promulgated by the Medical Provider Committee Report on December 9, 2014, UCR can be determined by looking to many programs: Fair Health Allowed Module, New Jersey Personal Injury Protection Fee Schedule, Provider/Carrier Commercial Payments, CMS, Wasserman Fee Schedule, , Pennsylvania Workers Compensation Fee Schedule, the New York Workers Compensation Fee Schedule, Federal Workers Compensation Fee Schedule, and any other probative evidence of paid charges received and accepted by the Medical Provider or paid by the carrier.
What This Means for Healthcare Providers
Under the Burn Surgeons case, when determining the amount of money to be charged for authorized medical treatment in a work-related injury, healthcare providers should use universally adopted databases, codes, and modifiers in order to determine whether the payments conform to UCR standards.
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!
Learn More About Callagy Law Here:
Medical Provider Applications In New Jersey Workers’ Compensation Courts
No comments:
Post a Comment