Callagy Law Arizona: 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.

The question of what constitutes payment for the purpose of calculating the Statute of Limitations in a PIP Claim for Benefits was recently addressed by our office in the Context of a PIP Arbitration filed on behalf of one of our Medical Provider’s.

The issue our Provider faced, as presented by CURE Insurance, was whether the Provider’s Claim was barred by the application of the 2 year statute of limitations period in connection to the filing of a PIP Arbitration Matter.

In relation to the calculation of the Statute of Limitations time period when filing a PIP Claim for Benefits, N.J.S.A. 39:6A-13.1(a) states:

Every action for the payment of benefits payable under a standard automobile insurance policy pursuant to sections 4 and 10 of P.L. 1972, c. 70 (c. 39:6A-4 and 39:6A-10), medical expense benefits payable under a basic automobile insurance policy pursuant to section 4 of P.L. 1998, c. 21 (c. 39:6A-3.1) or benefits payable under a special automobile insurance policy pursuant to section 45 of P.L. 2003, c. 89 (c. 39:6A-3.3), except an action by a decedent’s estate, shall be commenced not later than two years after the injured person or survivor suffers a loss or incurs an expense and either knows or in the exercise of reasonable diligence should know that the loss or expense was caused by the accident, or not later than four years after the accident whichever is earlier, provided, however, that if benefits have been paid before then an action for further benefits may be commenced not later than two years after the last payment of benefits.

(emphasis added).

Specifically, the facts of our matter showed that while there were no actual pip benefits paid by CURE, it was undisputed that CURE received the Provider’s Bill and processed the bill, applying the eligible amount (as determined by CURE) to the patient’s policy deductible.

Our office relied on the case of George C. Everett v. State Farm Indemnity Co., 358 N.J. Super. 400 (App. Div. 2002), wherein the Appellate Division found that the term “last payment of benefits” as used in N.J.S.A. 39:6A-13.1(a) is consistent with and includes the adjustment of a bill and application of that bill to the patient’s deductible.

Specifically, our office highlighted that in Everett, 358 N.J. Super. at 379, the Court found:

“since the bill was an expense caused by the accident, we conclude that the process of adjusting the bill to the fee schedule and applying the balance to the deductible constituted a ‘last payment of benefits’ under the Act, making the plaintiff’s complaint, which was filed within two years of that date, timely.”

Our office maintained that based on the determination of the Court in Everett, even though the adjustment/ processing of the Provider’s bill in this matter resulted in no more than a credit against the patient’s deductible, this was considered a benefit to the insured and therefore the date of processing of the bill sets the statute of limitations period once again.

In considering the above arguments, DRP Gary T. Lesser, Esq., in NJ-1644666 determined that based upon the Everett matter, the two-year statute of limitations commenced anew with the processing the bill and application of the payment against the patient’s deductible. As such, the Statute of Limitations period did not expire prior to the Provider’s filing of the PIP Demand for Arbitration. Therefore, as a result, the Provider had standing to Proceed with the underlying PIP Claim for Benefits.

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.

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The Definition of “Payment” When Calculating The Statute of Limitations in PIP Arbitration Matters

Important Information Regarding Carrier Underpayments in Personal Injury Protection Claims

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.

Do you have the proper information regarding carrier underpayments? Everyone is generally familiar with payment denials in PIP. They are usually for some form of lack of medical necessity—IME Denial, MDR Denial, Maximum Medical Improvement has been reached—or some shortcoming on the part of the patient–Lack of Eligibility or Failure to Cooperate. But there are also many reasons why carriers might unreasonably underpay claims that are sometimes more difficult to detect. Some of these reasons are discussed below.

21-Day Notification. Medical providers must notify PIP carriers that they are treating a patient injured in a motor vehicle accident (MVA) within 21 days following the commencement of treatment. If not, the insurance carrier can apply payment reductions in the following manner:

22 to 30 days after the commencement of treatment: 10 percent reduction.

31 to 60 days after the commencement of treatment: 25 percent reduction.

61 to 120 days after the commencement of treatment: 50 percent reduction.

121 to 160 days after the commencement of treatment: 75 percent reduction.

161 or more days from the commencement of treatment: 100 percent reduction.

New Jersey Administrative Code 11:3-25.

If the services were performed in an emergency context, the carrier cannot apply these reductions. It is important to understand these regulations so that PIP carriers are not unduly penalizing your practice.

Pre-certification Penalties. These reductions are fairly common. Medical products and services are required to be pre-certified when performed on a patient injured in an MVA, and a pre-certification denial must be appealed in a timely fashion to avoid a pre-certification penalty. These requests and appeals should be done immediately and a provider needs to make sure they obtain and retain proof that pre-certifications were sent and received. If not done properly and in a timely manner, the provider might have to suffer a 50% payment penalty.

Fee Schedule Payments. Reimbursements for PIP claims in the State of New Jersey are governed by a state-mandated fee schedule. This does not mean that PIP claims paid “according to the fee schedule” are always paid at the correct amounts. First of all, not all codes are on the fee schedule, which can generate controversy as to the appropriate reimbursement amount. There are also disputes as to what codes might or might not be separately reimbursable, and under what circumstances. There are multiple procedure reductions that sometimes are misapplied. And there are flat-out mistakes, as where a carrier pays an ASC the physician rate or vice versa. Any payment which seems inconsistent with amounts set forth on the fee schedule should be closely scrutinized.

Downcoding. Another reason underpayments occur is down coding. Because there are levels of complexity with things like office visits—some visits requiring more time for effective evaluation than others—there can be debate as to the correct level of reimbursement. Downcoding occurs when the carrier believes a lower level of payment is called for than the level billed, so they will pay at the lower-level CPT Code.

This is not an exhaustive list of why underpayments can occur, but it is some of the more common ones.

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.

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