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Monday, June 13, 2016

Palliative Care Under New Jersey PIP Laws

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.

As a claimant attorney in New Jersey PIP arbitration, I often seek reimbursement for treatment that was denied by insurance companies because the treatment was “palliative.” My response is, the palliative nature of the care is not ipso facto grounds to deny such treatment. Just like curative medical treatment, palliative care is compensable when medically necessary and reasonable.

What is “palliative care”? Palliative care is treatment that provides relief for the patient without curing the underlying cause of the symptoms. Dispute Resolution Professional (DRP) Fannan explained the standard to determine if palliative care is compensable under the New Jersey PIP laws in the Forthright Arbitration matter 1595197, as follows:

“Further, after treatment to effectuate a cure or rehabilitation has ended and the patient’s condition has plateaued, medical expenses for palliative treatment may continue, but only to the extent that such expenses are deemed reasonable and necessary. The reasonableness and necessity of palliative expenses must be evaluated in the context of the quantum of pain involved, plaintiff’s tolerance of pain and the overall effect of the pain on plaintiff’s life. Perun v. Utica Mutual Insurance Company, 280 N.J. Super 280, 285-86 (Law Div. 1994). The services must be shown by competent medical testimony to be such as are reasonable and necessary for the particular patient, taking into consideration his individual condition and need. Howard v. Harwood’s Restaurant Company Rest. Co., 25 N.J.

72 (1957). In determining what is reasonable and necessary, the “touchstone is not the (patient’s) desires or what he (sic) thinks is to be most beneficial. Rather it is what is shown by sufficient competent evidence to be reasonable and necessary to cure and relieve him (sic).” Squeo v. Comfort Control Corp. , 99 N.J.588(1995).”

By way of background, medical providers are expected to generally follow Care Paths, which are suggested general treatment paths to address injuries. For example, a Care Path may allow for a certain period of time of conservative care, and if the patient is still symptomatic, it may be time to “move up” the Care Paths to the next level of care. Perhaps injection treatment would be the next level of care following conservative care. There may be medical reasons to deviate from the Care Paths, and the treating doctor should explain the reasons for the deviation.

Let’s say the patient has been treated through all levels of the Care Paths for the injury at hand, but the patient is still suffering. Is palliative care still permitted and compensable under the New Jersey PIP laws. As noted above, generally palliative care is held compensable when it is medically reasonable and necessary. Elkins v. New Jersey Mfrs. Ins. Co., 203 N.J. Super. 695, 701 (App. Div. 1990). The PIP insurance carrier has a duty to provide payment for treatment which results in the alleviation of pain to the patient, even without regard to the curative aspect of that treatment. Miskofsky v. Ohio Cas. Ins. Co., 203 N.J. Super. 400, 413-414 (Law Div. 1984).

For example, Forthright DRP Miller ruled as follows in the Forthright PIP Arbitration matter 1337517:

“Medically necessary” is defined as treatment or a diagnostic test that is “consistent with the clinically supported symptoms, diagnosis or indications of the injured person”. In addition, that treatment is “the most appropriate level of service that is in accordance with the standards of good practice and standard professional treatment protocols including the Care Paths” and is “not primarily for the convenience of the injured person or provider”. N.J.A.C. 11:3-4.2.

The term “clinically supported” is defined in N.J.A.C. 11:3-4.2 and essentially means that there must be sufficient medical evidence and analysis to justify the performance of the requested treatment. This includes a physical examination, a review of both subjective complaints and objective findings, prior tests and a record of these observations and conclusions.

In addition, the treatment must be palliative or curative of a condition, not simply something that was provided for the patient’s personal comfort. See, Perun v. Utica Mut. Ins. Co., 280 N.J. Super. 280 (Law Div. 1994). See also, Elkins v. New Jersey Mfrs. Ins. Co., 244 N.J. Super. 695 (App. Div. 1990); Miskofsky v. Ohio Cas. Ins. Co., 203 N.J. Super. 400 (Law Div. 1984); N.J.A.C. 11:3-4.2.

In sum, palliative care very well may be compensable under the New Jersey PIP laws. The treating doctor should explain the patient’s condition and the need for the medical treatment, whether curative or palliative.

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 $200,000,000 for medical providers, and that number grows daily. Our team of knowledgeable PIP Arbitration attorneys are ready to help you. 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.

Learn More About Callagy Law Here:

Palliative Care Under New Jersey PIP Laws

Monday, May 23, 2016

Navigating The “Health Care Primary” Option in PIP Claims

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.

As a PIP litigation attorney, I frequently find myself explaining what PIP is to individuals who are not familiar with this area of practice. I generally explain it by stating that injuries sustained in auto accidents are covered by auto insurance in the state of New Jersey and I represent health care providers in cases where the auto carrier denies payment. A follow-up question I sometimes receive is, “why aren’t those injuries covered by health insurance?”

The answer to this question is simple, except when it isn’t. (I kid.) New Jersey mandates that all auto insurance policies cover a minimum of $15,000 of PIP coverage. Typically, the auto insurer is the primary payor of injuries sustained in an auto accident under this PIP requirement. Thus, in such cases, it is the auto insurer that is primarily liable and not the patient’s health insurer.

However, there is an exception to the default system which is called “health care primary.” This refers to instances where the insured, in selecting her auto coverage, opts for the “health care primary” option. Essentially, in selecting this option, the insured is committing to utilize health insurance as the primary payor of injuries sustained in auto accidents in exchange for a lower auto insurance premium. In such cases, the patient’s auto insurance serves as a secondary payor rather than as the primary payor.

Health care primary policies can put a wrinkle in health care providers’ standard billing practices for PIP cases and it is worthwhile to understand how to navigate this situation. If a provider treats a car accident victim with a “health care primary” auto policy, the provider should first bill the patient’s health insurer. (If the provider mistakenly bills the auto insurer first, the auto insurer will likely deny the claim and the provider can simply bill the health insurer thereafter.)

The question then becomes, what happens if the patient’s health insurer denies the claim? The good news here is that the provider can often bill the patient’s auto policy following such a denial since the PIP provision of the policy continues to act as secondary coverage.

While there is some ambiguity on this issue, many interpret the law in a way that requires the patient’s health insurer to issue a substantive denial in order for PIP to be triggered as secondary coverage.

For example, if the health insurer denies the claim because the treatment is not covered under the patient’s policy, this would serve as a substantive denial and the provider would then be free to bill the patient’s auto insurer. However, if the health insurer denies the claim stating that more documentation is needed to process the claim, this will likely not be regarded as a substantive denial and the provider would be wise to resubmit the claim to the health insurer with the requested documentation prior to attempting to bill the patient’s auto carrier.

One final note to be mindful of is, when billing the auto carrier following a health insurance denial, be sure to include the health insurance EOBs. This will signal to the auto carrier that, even though the claim involves a health care primary policy, the patient’s health insurer was already billed but the claim was denied.

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Navigating The “Health Care Primary” Option in PIP Claims

Monday, May 9, 2016

What is No-Fault Auto Insurance and How does the Arbitration Process Relate?

One of the primary functions of Callagy Law, P.C. is the representation of New Jersey medical providers for collection of unpaid medical bills incurred as the result of motor vehicle accidents, which operates within the construct of what is called “Personal Injury Protection.”

To understand the relationships at play, the first thing to understand is that under New Jersey Law, all operators of Motor Vehicles must carry automobile insurance. This insurance can be obtained in two forms, “liability only,” or “liability plus collision.” The difference between the two is that the former is limited to payment of vehicular damage of another party’s vehicle – should it be determined that the accident was your fault. The latter includes coverage for damage to your own car in addition to damage caused to another person’s.

However, what many people do not realize is that, if you are injured as a result of a motor vehicle accident, the primary payor (i.e. insurance company) will typically default to your automobile insurance, not any personal health insurance that you may have. This is termed as the PIP coverage portion of your automobile insurance.

If a party is injured in an accident, their default payor will be their own car insurance company, not the other party involved in the accident, even if you feel the accident was caused by them. This is because New Jersey is one (1) of twelve (12) “No-Fault” states.

Specifically, the term “no-fault” auto insurance generally refers to any auto insurance plan that allows policyholders to recover reimbursement from their own insurance company, regardless of fault. However, the State of New Jersey utilizes the strictest definition of no-fault coverage, which provide for the payment of no-fault first-party benefits and restrict the right to sue any third parties with regard to the accident. As noted above, this “policyholder benefit coverage” is known as personal injury protection (PIP). [See: Insurance Information Institute, “No Fault Auto Insurance”- http://www.iii.org/issue-update/no-fault-auto-insurance]

Currently 12 states and Puerto Rico have no-fault auto insurance laws. Florida, Michigan, New Jersey, New York and Pennsylvania have verbal thresholds of PIP coverage. However, in New Jersey, Pennsylvania and Kentucky only, motorists may reject the lawsuit threshold and retain the right to sue for any auto-related injury. [Id.]

Therefore, in the most typical situation, when a patient is injured, and requires medical treatment, their personal car insurance company is responsible for making the appropriate covered payments. However, in many cases, the insurance companies’ unjustly deny payment based on purely procedural or theoretical grounds, or based upon differences in medical opinions between the patient’s doctors’ and the insurance companies’ hired “physician experts.”

Therefore, to take the burden of establishing the medical necessity of post-accident treatment, most patients “Assign” their right to payment to the physicians, who must then seek to recover any underpayments on their own accord, as subrogee of the insured patient. In order to protect their right to payment, the matters of PIP disputes are contractually stipulated to take place within an authorized New Jersey Arbitration Forum, rather than the more costly State Judicial System (ie Court).

At present, a company called “Forthright” administers New Jersey No-Fault Arbitrations, wherein its sole focus is management of No-Fault PIP Arbitrations under the State’s Automobile Insurance Cost Reduction Act. [See http://www.nj-no-fault.com/]

Callagy Law, P.C. represents all facets of medical providers from all stages of the arbitration process. We pick up your unpaid files, file the Demand for Arbitration, and send one of our highly skilled PIP-Litigation Specialized Attorneys to the scheduled hearing, where the provider’s argument for payment is presented to a Forthright Dispute Resolution Professional, who will subsequently render a decision, awarding the unpaid medical provider the fees to which they feel it is entitled. To date, almost $135,000,000.00 has been recovered for our PIP clients, a result of our 90% Claim Success Rate in the 44,000 cases that have been handled to date.

Learn More About Callagy Law Here:

What is No-Fault Auto Insurance and How does the Arbitration Process Relate?

Monday, April 11, 2016

Limited Policies Under New Jersey No-Fault Law

This blog will take a closer look into limited policies under New Jersey No-Fault Law – and examine basic versus standard policies.

New Jersey automobile insurance policies generally provide No-Fault, or PIP, coverage in the amount of $250,000.00 for medically necessary and reasonable medical treatment per person, per motor vehicle accident, for covered individuals. However, an insured may opt for reduced coverage limits. For example, an insured may opt for only $15,000.00 No-Fault coverage, per person, per motor vehicle accident. Does this limited amount apply to all individuals covered by the policy? As discussed below, the answer may vary depending on whether the governing policy is “basic” or “standard.”

“Basic” policies grew out of the Automobile Insurance Cost Reduction Act, known as “AICRA.” This law was passed in 1998 with an effective date of March 22, 1999. Under AICRA, a new class of PIP benefits was created, namely, “basic” coverage, to be distinguished from “standard” coverage. Basic policies provide for very limited medical coverage, and apply to all individuals covered by the policy. N.J.S.A. 39:6A-3.1 provides the following:

As an alternative to the mandatory coverages provided in sections 3 and 4 of P.L.1972, c. 70 (C.39:6A-3 and 39:6A-4), any owner or registered owner of an automobile registered or principally garaged in this State may elect a basic automobile insurance policy providing the following coverage:

Personal injury protection coverage, for the payment of benefits without regard to negligence, liability or fault of any kind, to the named insured and members of his family residing in his household, who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile, and to other persons sustaining bodily injury while occupying, entering into, alighting from or using the automobile of the named insured, with the permission of the named insured. (emphasis added)

Standard policies may also provide for limited policy coverage. A standard policy, however, only applies to the named insured and resident relatives. provides the following:

39:6A-4.3. Personal injury protection coverage options

Personal injury protection coverage options. With respect to personal injury protection coverage provided on an automobile in accordance with section 4 of P.L.1972, c. 70 (C.39:6A-4), the automobile insurer shall provide the following coverage options:

Medical expense benefits in amounts of $150,000, $75,000, $50,000 or $15,000 per person per accident; except that, medical expense benefits shall be paid in an amount not to exceed $250,000 for all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requires critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician.

An option elected by the named insured in accordance with this section shall apply only to the named insured and any resident relative in the named insured’s household who is not a named insured under another automobile insurance policy, and not to any other person eligible for personal injury protection benefits required to be provided in accordance with section 4 of P.L.1972, c. 70 (C.39:6A-4). (emphasis added)

Therefore, if a PIP carrier provides notice that a limited policy amount has been exhausted and no more medical bills will be reimbursed, request documents to demonstrate that the limited policy indeed applies. If the patient is not the named insured and is not a resident relative of the named insured, it is critical to determine if the governing policy is “basic” or “standard.”

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 $200,000,000 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.

Learn More About Callagy Law Here:

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Limited Policies Under New Jersey No-Fault Law

Friday, April 1, 2016

Decision Point Review Plans and Their Significance

In Part 1 of this series, we discussed Decision Point Review Plans (DPRP’s) and how they relate to pre-certification of medical treatment. There, we explained how understanding DPRP’s is critical to any medical provider who sees patients injured as a result of a motor vehicle accident (MVA). You will recall that 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, and that DPRP’s are filed with the state by PIP insurance carriers in order to set forth the substantive and procedural requirements needed for a medical provider to be reimbursed by the PIP carrier. DPRP’s enable carriers not only to 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.

In Part 2 of our discussion, we focus on payment appeal procedures. Basically, any medical provider can appeal underpaid, denied or unpaid PIP claims with the PIP carrier or a carrier-approved third-party vendor. It is the first step in the dispute resolution process, which might end in PIP arbitration. You should proceed carefully with this step because failure to appeal properly can result in a denial from the arbitrator at PIP arbitration. All approved DPRP’s have specific procedures for appealing payments and they vary widely from carrier to carrier. Let’s look at three key areas of difference.

First, some carriers require a specific form for use with appeals; others do not. The DPRP will include a copy of the form. Complete the form as required, paying close attention to the accuracy of the information you provide. Mistakes could cost you in the end. If a particular carrier does not require use of a specific appeal form, you can use your own form, as long as it contains all of the requisite claim information and enough detail as to why you are appealing the payment or non-payment.

Second, proper delivery of the appeal is critical. DPRP’s often include a description of the appeal delivery vehicle. Some require faxing. Some require certified mail. Some require regular mail. All DPRP’s will explain the appeal delivery process they require including addresses and fax numbers. Some DPRP’s will require two levels of appeal, and the fax number for the first level might be different from the second level fax number.

Third, it is essential to wait the proper amount of time after appealing before filing for arbitration. Every carrier requires a specific time to lapse after you appeal, and filing too soon might result in a denial at arbitration.

If your head is starting to spin from trying to fathom all of the variations in procedures among the dozens and dozens of New Jersey PIP carriers, take heart. Knowing all of this, and doing the payment appeals for you to ensure all of the t’s are crossed and i’s are dotted, Callagy Law is standing by. We manage the labyrinthine payment appeals process for you to ensure that carriers, who intentionally look to complicate the process, do not benefit from this undue complexity. Payment appeal procedures are not to be taken lightly, and not understanding or following the correct process can be a grave financial mistake.

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.

Learn More About Callagy Law Here:

Decision Point Review Plans and Their Significance

Wednesday, March 23, 2016

Facility Fees vs. Physician’s Fees

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.

In the heavily regulated world of PIP (personal injury protection), it is important to distinguish between facility fees and physician’s fees, to ensure that, as a medical provider, you are receiving the appropriate form of reimbursement.

In New Jersey, auto insurers are required to provide a minimum of $15,000 in PIP coverage to everyone they insure. In practice, the amount tends to be much higher as the default option for PIP coverage is typically $250,000. To guard against endless PIP claims leading to ever increasing insurance premiums, the Department of Banking and Insurance (DOBI) promulgates fee schedules which essentially cap the amount of reimbursement providers can receive for the treatment they perform.

What is important to be mindful of is that there are many different kinds of healthcare providers and, in recognizing this concept, DOBI has set forth various different fee schedule rates.

The simplest example of different providers receiving different amounts of reimbursement for the same treatment performed is a physician versus a facility. It is somewhat intuitive that a facility charge is distinct from a physician charge and the fee schedules put forth by DOBI take this into account.

What further confuses this issue is the fact that, even within the category of facility charges, there are several different types of facilities. This too is accounted for by DOBI which distinguishes between various types of facilities.

For the most part, a facility charging a fee for medical services that it hosted, fits into one of three categories: a hospital, an ambulatory surgical center (ASC), or “other” (pretty much anything else).

The fee schedule rates for these various charges can be found on the DOBI website using the following link: http://www.state.nj.us/dobi/pipinfo/aicrapg.htm. Exhibit 1 contains a column titled “physician’s fees” and a separate column titled “ASC fees.” Thus, it is pretty simple to search and find the proper reimbursement for a physician charge or an ASC facility charge.

With respect to the “other” facility category previously mentioned, meaning facilities that are neither an ASC nor a hospital, the facility fees can also be found in Exhibit 1- they are listed in the physician’s fee column but they include the TC modifier (technical component). So, for example, let’s say a patient undergoes an X-ray of the jaw which is billed under CPT Code 70100. The “physician’s fee column” lists this CPT Code twice- once with the 26 modifier and once with the TC modifier. (To be complete, it also lists it a third time without any modifier which represents a global fee but that is beyond the scope of this article.) Assuming the CPT Code is being billed twice, once by a physician and once by a facility, the physician would bill with the 26 modifier and receive the corresponding fee schedule reimbursement, while the facility would bill with the TC modifier and receive payment accordingly.

Finally, we get to hospitals which are truly a category of their own. Hospitals have their own fee schedule known as the Hospital Outpatient Surgical Facility or HOSF fee schedule. (This fee schedule can be also be found using the link posted earlier.) However, the HOSF fee schedule, as the name indicates, is really only applicable to cases of outpatient surgery. Thus, if the previously cited example of a patient undergoing an X-ray took place in a hospital, the hospital would not be reimbursed for the X-ray pursuant to the HOSF unless the exam was in connection with outpatient surgery (such as pre-op testing).

So how is a hospital to be reimbursed for facility fees that are not associated with outpatient surgery? Callagy Law takes the position that hospitals are not subject to any fee schedule for (non-surgical) treatment provided to hospital outpatients. Such charges are subject to the hospital’s usual and customary rate. Insurance carriers tend to be in acknowledgment of this in the way that they reimburse emergency room visits, typically billed under one of the 9928X treatment codes. However, when it comes to other hospital treatment such as diagnostic testing, even when performed in conjunction with emergency room encounters, carriers tend to apply the TC rate of the physician’s fee schedule referred to earlier. Callagy Law has had an enormous amount of success in arbitration reversing these applications of the TC rate which are inapplicable to hospital outpatients.

It is important to remember that an insurance carrier’s determination as to how a claim should be paid is not necessarily correct. If you suspect that a claim was not paid correctly, or you simply are uncertain, be sure to reach out to Callagy Law, PC.

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.

Learn More About Callagy Law Here:

Facility Fees vs. Physician’s Fees

Monday, March 14, 2016

“A personal and professional perspective from an employee of Callagy Law” – Mark H. Winters, Jr., paralegal

Personally, the field of PIP represents a step in my career that allows me to take part in something important, something helpful, and something that can help work within a broken system for the greater good. Professionally, working in PIP at Callagy Law has exposed me to some of the brightest attorneys, who quite frankly I feel have revolutionized arbitration on a number of pertinent issues, all without cost to the clients.

In explanation of my enthusiasm in PIP, it is relevant that the first eight (8) years of my legal career I was involved largely in consumer collections litigation, a particularly dreary aspect of law. Spending so much time in that field, it begins to cloud your overall perspective on the very nature of law, people, and even yourself. Luckily, in June 2014, I took the opportunity to work in the PIP department at Callagy Law.

Now, at first, I was not even clear on what working in PIP would mean, or if anything could improve my jaded outlook of the law. However, integrating myself into the world of PIP was almost therapeutic. This was an opportunity to do something good, for the first time in my career representing the “good guys,” and it was exiting to find that the remainder of Callagy Law was likewise enthused. For, after all, who does it feel better to help than those who dedicate their lives to helping others?

Notably, in PIP we get to represent a huge variety of doctors and institutions, each of whom are essential for an immeasurable amount of car accident victims. Throughout the days and weeks, we handle cases involving everything from initial Hospital Emergency Room visits, to the initial stages of treatment (ie. chiropractic, physical therapy), then moving along to more advanced and complicated treatment providers, including specialized dental practitioners, pain management physicians. Whether it is underpayment of services, or an outright denial of necessary treatment, we argue on behalf of the treating doctors, who typically provide the patient with the necessary care even at the risk of insurance denials. It is here that my job comes in, helping those doctors get payment for the services they rendered to their patients in good faith.

In fact, one thing I did not know before starting in PIP, and what actually may make Callagy Law unique among PIP practitioners, is that we even represents pharmacies who issue prescribed medications that insurance companies nevertheless fail to pay for. I have even seen reimbursements awarded to psychologists and counselors whose post-traumatic stress therapies are denied prematurely. So, yes, I found that even such apparently ancillary providers such as pharmacies, dentists, and psychologists can benefit from an attorney’s PIP services.

In short, while I was feeling quite negative about the field and practice of law before starting in PIP, working for the benefit of the medical field to encourage fair payment, and in recovering the amounts unjustly denied, means something to me, to this firm, and, I like to think, our clients as well.

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.

Learn More About Callagy Law Here:

Friday, March 11, 2016

Let’s Call It What It Is—An Implied Assignment of Benefits

An Assignment of Benefits (AOB) in the world of No-Fault Law, also known as Personal Injury Protection (PIP), is critical in order for a medical provider to be reimbursed by a PIP insurance carrier. Indeed, a contractual relationship exists between the patient (insured) and the carrier (insurer), but no such relationship exists between the carrier and the medical provider. The AOB is what transfers, or “assigns,” the patient’s rights to receive PIP benefits to the medical provider. Without it, the medical provider would have no legal right to claim reimbursement from the carrier.

So, why and how is it that very often claims are allowed to go forward when there is no signed AOB, or the AOB that is presented is sufficiently defective as to render it not truly an effective legal instrument to transfer rights, or it is executed by someone who clearly would not have the right to effectuate such an assignment. These instances often present themselves in the context of Emergency Room (ER) treatment, where the niceties of signing intake forms and other consents do not exist because of the traumatic nature of the events, injuries and treatment. The atmosphere by its very nature is emergent and therefore warrants consideration beyond the standard practices found in by-choice, pre-scheduled doctor visits and procedures.

In these situations, PIP arbitrators, known as Dispute Resolution Professionals (DRPs), at times do allow the claims to go forward when there is no AOB, or it is signed by hospital personnel, or it is signed by a stranger to the patient’s policy, or it is somehow otherwise defective. They do this in recognition of fundamental fairness and equity, because there is no dispute as to the carrier’s liability. There is only the defect of the nonexistent or defective AOB. Though it is rarely recognized as such, the legal conclusion being drawn by these DRP’s is that an implied AOB exists.

In effect, even though the patient has not signed an AOB, which would expressly and unequivocally transfer to the ER doctors and hospital the right to recover PIP benefits, the circumstances dictate that the patient implies an assignment when they accept treatment under the circumstances. Indeed, hospitals are required by law to treat anyone who comes into the ER, regardless of their ability to pay and regardless of insurance. Therefore, it seems only fair that in the circumstances of ER treatment, medical providers should be able to pursue PIP carriers in arbitration regardless of a written AOB, because an assignment is clearly implied from the circumstances.

For more information on AOB, please read our blog:

Why I an Assignment of Benefits So Important?

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.

Learn More About Callagy Law Here:

Let’s Call It What It Is—An Implied Assignment of Benefits

Tuesday, February 23, 2016

Interlaminar vs. Transforminal Injections | Callagy Law

When disputing the use of a Transforaminal Injection as opposed to an Interlaminar Injection, Transforminal Injections have proven to present less risk to the patient and be more cost effective for a provider.

Specifically, regarding the differences between Interlaminar and Transforaminal Injection Approaches, studies have clearly established the following:

The interlaminar approach is the most common way of performing an epidural injection for all indications in anaesthesia […]This can be done with or without fluoroscopic guidance, but one of the many queries with regard to the varying efficacy of epidural steroid in studies has been the uncertainty of whether, by caudal or interlaminal route, the steroid has been accurately placed at the required site.

(See, “Epidural Steroids,” by Neil Collighan and Sanjeeva Gupta MD)

On the other hand:

The transforaminal approach is a selective injection aimed at a specific level and is always done under fluoroscopic guidance. […] Both the interlaminar and transforaminal approaches can be used at the cervical, thoracic, and lumbar levels. The benefits of the transforaminal approach, when performed by an experienced clinician, may include decreased risk for dural puncture with delivery of smaller volumes of steroid to the appropriate site of considered pathology. (emphasis added). [Id.]

In fact, in one recent study, the researcher concluded:

Transforaminal injection [is] superior in its ability to reach the site of pathology while being able to use even smaller doses of steroids. While the increased technical difficulties are noted to perform this method, his study showed better outcomes after a series of epidural steroid injections [with] the transforaminal approach followed by the caudal approach as a reasonable secondary approach.”[Id.]

Additionally, there is an established difference in cost effectiveness between the intralaminar method and the transforaminal:

Evaluation of the cost effectiveness of epidural injections including transforaminal steroid injections for the management of chronic low back pain revealed […] cost effectiveness of caudal epidural steroids at $3,635.00 and transforaminal steroids at $2,927.00 per year.

(See, “Transforaminal Lumbar Epidural Steroid Injections,” by Laxmaiah Manchikanti, MD)

Furthermore, with respect to the efficacy of the various injection methods:

the transforaminal epidurals appear to be clinically effective with a favorable outcome and cost effectiveness, compared not only to blind interlaminar epidural steroid injections and fluoroscopically directed caudal epidural steroid injections but also to numerous other modalities of treatment.”[Id.]

As stated above the Transforminal approach presents less risk of a dural puncture with the delivery of smaller volumes of steroid to the appropriate site of injury. The studies also showed better outcomes after repeat series of epidural injections via the Transforaminal approach as opposed the Interlaminar approach. Based on these recent studies and that fact that Transforminal injections represent a saving of up to $800 a year clearly demonstrate that the Transforminal approach is a better option for the health of the patient and for the treating provider.

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.

Learn More About Callagy Law Here:

Interlaminar vs. Transforminal Injections | Callagy Law

Friday, February 5, 2016

Healthcare Primary and What That Means for PIP Claims

Important developments regarding Health Insurance Primary (HIP) and other relevant information.

Health Insurance Primary (HIP) means your health care insurer is primarily responsible for your medical bills after an automobile accident. This means that after an accident, your health insurer will be billed first by your medical provider, and then, depending upon what the health insurer paid or did not pay, your automobile carrier will be billed.

The implications of this for a medical provider are that the provider needs to bill the health insurer, and then, if the medical provider is still paid below what is appropriate under any applicable fee schedules or usual and customary rates, they should then bill the PIP carrier for the balance between what they are entitled to under the law and what they were paid by the health insurer. When the PIP carrier is billed in such an instance, the health carrier’s explanation of benefits needs to be included with the bill.

Not all health care plans are compatible with HIP. Before choosing this option in an auto policy, a consumer should know exactly what is and is not covered in the health care policy. Cost savings can be a reason why people choose to select their own health insurance as a primary source of coverage, because an auto policy will generally be cheaper with this option. However, if HIP is selected with an incompatible health care plan, the consumer will need to pay an additional $750 deductible before collecting from PIP insurance. MEDICARE and MEDICAID cannot be used for the HIP option. If you are not certain of what your health insurance covers, you should select Full PIP Primary for your auto insurance coverage.

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Healthcare Primary and What That Means for PIP Claims

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?

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.

Learn More About Callagy Law Here:

Codes Not On ASC Fee Schedule Possibly Reimbursement | Callagy Law

Monday, January 18, 2016

Upcoming Shortage of Physicians | Callagy Law

Difficulties Facing the American Healthcare System – What You Need To Know!

There are many difficulties facing the American healthcare system, but perhaps chief among them is a possible shortage of physicians. The Association of American Medical Colleges (AAMC) predicts that an approximate shortage of 90,000 – 130,000 physicians will occur in the US by the year 2025. There are many factors contributing to this problem, including inadequate enrollment in medical schools.

Many new allopathic (M.D. granting) and osteopathic (D.O. granting) medical schools have been established in recent years, with overall medical school enrollment expected to increase by 30% by 2019. New Jersey has recently started Cooper Medical School of Rowan University and Seton Hall School of Medicine to help meet the health care needs and many other states are following suit.

While increasing the number of medical schools would help to alleviate this shortage, perhaps a more important and overlooked issue is reduction in the fund of residency positions. A residency is a multi-year education program medical school graduates must complete before they can become practicing physicians or surgeons. In 1997, Congress capped the number of Medicare-supported residency positions. In other words, even if we add medical school graduates by increasing the number of medical schools, we will not add to the number of practicing physicians unless we also add to the number of residency training programs. A bill was introduced that would increase residency positions in 2012, but Congress has yet to act on the bill.

The AAMC urges all Americans to rally for support of this bill, and while it will not entirely fix the projected physician shortage, it seems to be a step in the right direction.

Sources

http://www.ama-assn.org/ama/pub/news/news/2015/2015-03-05-ama-applauds-congress-modernize-graduate-medical-education.page

https://www.aamc.org/newsroom/newsreleases/305476/120928.html

https://www.congress.gov/bill/112th-congress/house-bill/6562

https://www.aamc.org/newsroom/newsreleases/431036/20150430.html

Photo Credit: www.vox.com

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 you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Upcoming Shortage of Physicians | Callagy Law

Tuesday, January 5, 2016

Can PPOs and PIP Coexist? | Callagy Law

The purpose of this post is to help assist healthcare providers and owners with questions they have concerning their business or relevant knowledge in the field. 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.

Health care providers are all too familiar with PPO agreements. While these contracts certainly provide a benefit to providers, they ultimately cut into their reimbursement on applicable claims. An interesting question, though, is what happens in an instance where a PPO contract conflicts with a PIP Medical Fee Schedule?

Typically, insurance carriers will apply a PIP fee schedule rate regardless of whether or not an applicable PPO contract exists, provided of course that the PPO rate exceeds the fee schedule rate. If the PIP fee schedule rate exceeds the PPO rate, then the insurer will likely apply the PPO rate. In other words, in determining whether to reimburse the provider according to the PPO or according to the PIP fee schedule, insurance carriers are likely to pay the lesser amount.

While this may seem like an unfair ploy by the insurance carriers to pay out as little as possible (it is), it is not without legal basis. PPO contracts have been deemed entirely enforceable and consistent with the PIP No-Fault scheme; however, it is well understood that parties cannot contract outside of the law as such would violate public policy. Thus, insurance carriers make the case that the PIP fee schedule is a government regulation capping the rate of PIP reimbursement, and a PPO contract exceeding that rate is not enforceable.

While there is merit to this insurance friendly argument, it is open to legal dispute. Health care providers can make the argument that the parties’ freedom to contract trumps the PIP fee schedule and, on occasion, PIP arbitrators will find in the Claimant’s favor on this issue. One has an even greater chance of achieving this result if the carrier applies a PPO rate to at least part of the claim. For example, in a case where the provider bills for multiple treatment codes and not all of these codes are found on the PIP fee schedule, the carrier will likely reimburse the fee schedule rate where applicable, and the PPO rate where the fee schedule is not applicable. In such a case, the provider can argue that the carrier has effectively acknowledged the applicability of the PPO to the claim, and the entire claim should therefore be governed by the PPO contract.

To be sure, some PPO contracts specifically state that reimbursement should be rendered pursuant to the lesser of the PPO rate or any applicable State fee schedule. In such cases, the provider has little if any chance of escaping the applicability of the PIP fee schedule given the express terms of the contract. However, the fact that the drafters of these contracts find it necessary to include such language gives credibility to the argument that, absent such language, the PPO rate should stand despite the existence of the PIP fee schedule.

As for whether receiving reimbursement pursuant to the PIP fee schedule rather than at a PPO rate warrants the filing of a PIP arbitration, this is not entirely clear as this issue more often than not is decided in the insurance carrier’s favor. However, it is certainly another issue to be mindful of for cases that are already facing arbitration for an entirely different issue. The more issues a provider can raise in a given case, the more likely they are to receive an award of reimbursement.

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 you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Can PPOs and PIP Coexist? | Callagy Law

Tuesday, December 29, 2015

A Closer Look into Bundling & PIP Regulations | Callagy Law

The Bucket 4 “Carve Out”

After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. 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 and medical revenue recovery. Our mission is to answer any questions and give knowledge to many different aspects of these matters

This blog is a little bit “inside baseball,” in that it’s a hyper technical explanation look at a concept in the world of bundling. If you’re a PIP practitioner, however, or deal with ASCs and Hospitals, this is an important concept that could lead to a much larger amount of recovery/reimbursement for ASCs or Hospitals

When DOBI updated the PIP regulations (effective 1/4/13) the update included a new section on the “bundling” of outpatient surgical services. Specifically, N.J.A.C. 11:3-29.5(a)(1-8) and N.J.A.C. 11:3-29.5(b) (which incorporates (a)(1-8)) inform providers and carriers which services are considered “bundled” and are not separately reimbursable.

The code, in relevant part, reads as follows:

11:3-29.5 Outpatient surgical facility fees

ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fee include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including:

Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;

All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient’s care;

Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment;

Diagnostic and therapeutic items and service. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp, CMS-1504-FC, Exhibit AA), are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare are considered ancillary services that according to Medicare (see: https://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_

D1.pdf) are integral to surgical procedures and are not permitted to be reimbursed separately in a HOSF;

Administrative, recordkeeping, and housekeeping items and services;

Blood, blood plasma, platelets, etc.;

Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and

Implantable DME and prosthetics.

(b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The hospital outpatient surgical facility fee is the maximum that can be reimbursed for outpatient procedures performed in an HOSF. The hospital outpatient facility fees in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through (8) above.

(a)(1-8), which I’ll colloquially refer to as the “8 buckets,” essentially states that each bucket is included in the main surgical procedure that was performed in the ASC or Hospital on that particular date of service, and that the type of service described by that bucket is not separately reimbursable, since DOBI has already included reimbursement for such services in the price of the ain surgical code on the appropriate fee schedule.

There is a catch, however. N.J.A.C. 11:3-29.5(a)(4) states:

Diagnostic and therapeutic items and service.

Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare … are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC.

Appendix, Exhibit 7 indicates those services that, according to Medicare are considered ancillary services that according to Medicare… are integral to surgical procedures and are not permitted to be reimbursed separately in a HOSF;

Callagy Law’s PIP attorneys have been successful in arguing that bucket 4 actually is actually a “carve out,” and should be read and interpreted differently than the other 7 buckets. Our attorneys argue that bucket 4 requires a carrier to not simply state that all diagnostic and therapeutic items and services are automatically included in the main surgical procedure; rather, the carrier must first identify the diagnostic and therapeutic items and services and then proceed to the appropriate fee schedule (Exhibit 1 for ASCs, and Exhibit 7 for Hospitals) to determine whether those services are, in fact, bundled.

There is an entire column in Exhibit 7 (The Hospital Outpatient Surgical Facility Fee Schedule – “HOSF”), for example, titled “Packaged Item; No Separate Payment.” Our argument is that DOBI is directing providers and carriers to examine Exhibit 7 to see whether the particular diagnostic/therapeutic services being provided in a particular case are marked as bundled. (see screenshot of Exhibit 7 below)

Many diagnostic/therapeutic codes on the HOSF do have indicators in the column meaning that they are bundled, but many codes either have no indicator, or do not appear on the HOSF at all. In those cases, it is the position of the Callagy Law PIP attorneys that the diagnostic/therapeutic codes ARE entitled to separate reimbursement.

These diagnostic/therapeutic codes often add up to hundreds or thousands of dollars in a particular outpatient surgery, and so mastery of this concept can mean a great deal of additional recoverable money for a particular provider. This position has been successful with several arbitrators, and the wave of momentum for this argument only seems to be growing stronger.

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A Closer Look into Bundling & PIP Regulations | Callagy Law