Callagy Law Arizona: Decision Point Review Plans and Their Significance

Part 1: Pre-Certification

The purpose of this post is to help assist healthcare providers and the public with questions they have concerning topics related to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. The Callagy Law team is knowledgeable in all aspects of these sorts of legal matters and will frequently post topics in this field. We hope to have this article shine a light on many common questions.

Understanding Decision Point Review Plans or DPRP’s is critical to any medical provider who sees patients injured as a result of a motor vehicle accident (MVA). 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.

DPRP’s are filed with the state by PIP insurance carriers in order to set forth that carrier’s substantive and procedural requirements needed for a medical provider to be reimbursed by the PIP carrier. They enable carriers to not only 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.

Perhaps most importantly, DPRP’s are a tool for insurers to oversee the medical necessity of treatment. Carriers can deny approval of medical services and reduce or deny payment for medical treatment, when insurers feel the treatment does not comport with medical guidelines. Of course, these determinations are often quite subjective and can be challenged by the medical provider and firms like Callagy Law. In fact, when a medical provider disagrees with the determination, they should and must immediately appeal the denial to safeguard their interests.

Pursuant to the carrier DPRP’s, insurers are to be notified of treatment plans by treating medical providers. These notifications will be faxed to a designated fax number, established by the carrier, and will be reviewed for certification or denial within 72 hours from receipt. Along with the Attending Provider Treatment Plan Form (ATPT form), the treating provider will submit medical notes to support the requested treatment. When the requested treatment falls within medical guidelines or standards for treating that specific injury, insurers are supposed to approve the treatment, and send notice to that effect to the treating provider.

Those approvals usually come from nursing staff working for the insurer or a designated medical vendor working with the insurer. Should the nurse feel the treatment is not in line with current medical protocol, then the requested treatment will be sent to a doctor for review. The doctor reviewing the requested treatment is still held to the 72-hour rule, and if a denial or approval is not communicated within that 72 hours, the requested treatment will be considered approved. This rule is in place to ensure carriers do not hold up treatment for injured patients.

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.