DOBI HAS PROPOSED A NEW RULE AT NJAC 11:3-4.7B TO ESTABLISH UNIFORM APPEAL PROCEDURES THAT WE THINK MEDICAL PROVIDERS WILL LIKE
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.
On November 2, 2015, the New Jersey Department of Banking of Insurance (“Hereinafter “DOBI”) proposed amendments to certain current and pending regulations relating to the Internal Appeals procedures medical providers were required to comply with when faced with PIP denials. Under the old regulations and prior pending regulations, medical providers were required to strictly follow the specific procedures set forth in each insurance carrier’s (Hereinafter “Carrier”) Decision Point Review Plan in order in order to appeal.
As every medical provider, and every PIP attorney well knows, internal appeal procedures vary widely by both Carrier, and by type of appeal – meaning there is one set of procedures when appealing pre-service denials, such as precertification, and another set of procedures when appealing post-service denials, such as non-payment or under-payments. The only requirement placed upon the Carrier was that their internal appeals process must be published in its DOBI approved Decision Point Review Plan.
Also contained within these procedures are certain critical deadlines, which vary widely by Carrier. For example, one Carrier may require that any post service appeal be filed within 30 days of the denial, but require that any pre-service denial be appealed within ten days. Another Carrier may require pre-service denials to be appealed with 15 days but post service appeals be appealed within ten days. Keeping track of these deadlines on behalf of every Carrier can be quite complicated for the medical provider, yet it can become quite costly if they don’t.
Moreover, some Carriers impose a 2 level post-service appeal process while some require just one. Each level has their own unique timeline, as well. Further, some Carriers require that a first level appeal must be faxed to one number while second level appeals must be faxed to an entirely separate fax number. One Carrier even recently changed their requirements such that its first level appeal was required to be faxed to its 3rd party administrator, but its 2nd level appeal process required the medical provider to mail their appeal via certified mail only, with return receipt requested! Considering substantial supporting documentation is often required and included in a second level appeal, the size and cost of such a requirement imposed on the provider was quite burdensome.
Fortunately, in this most recent proposal, DOBI recognized that the varying internal appeals processes made it “complicated and burdensome” for providers to appeal and is now proposing to repeal and replace the current internal appeals process in its entirety.
In its place, DOBI is now proposing a uniform internal appeals process which must be adopted by all Carriers. [SEE IT HERE www.state.nj.us/dobi/proposed/prn09_207.pdf ]
The most significant changes for the medical provider in this latest proposal by DOBI include:
- A uniform appeal form;
- Carriers will be limited to one level of appeal only;
- Uniform critical deadlines; pre-service appeals must be submitted within 30 days of the denial and Carriers must respond within 14 days, post service appeals must be submitted 45 days prior to initiating dispute resolution and Carriers will have 30 days to respond;
- A clear definition of what constitutes a pre-service appeal and what constitutes a post-service appeal.
By and large, these changes are most welcome to the medical provider. Medical providers are well aware that, in addition to being complicated and burdensome, Carriers have repeatedly wielded the internal appeals process against the medical provider as a threshold weapon in arbitration. Compliance with a particular Carrier’s internal appeals process created a very fertile ground in the arbitration arena for a Carrier to argue that any variance, no matter how minor, forecloses the medical provider from ever being reimbursed for its services. The question of medical necessity is never reached. This defied the very purpose of internal appeals, which were instituted to provide a Carrier the opportunity to take a second look at a denial prior to being required to engage in costly arbitration or litigation.
Now however, should these proposed regulations be adopted, the internal appeals process will be uniform and simplified. Of course, arbitrators will continue to strictly enforce the regulations, but it appears the field will finally be leveled for the medical provider.
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.
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