Healthcare Primary and What That Means for PIP Claims

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

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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.

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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

The Importance of the Trauma Services “TS” Modifier

Trauma Centers are specially equipped and organized hospitals, specializing in caring for seriously injured patients. Trauma Center care guarantees the immediate availability of specialized personnel, equipment, and capabilities 24 hours a day. These centers work closely with each other and with local community hospitals to assure the best possible appropriate trauma care.  Level I and Level II Trauma Centers are located on a population and geographic basis across New Jersey.

 

The New Jersey Level I and Level II Trauma Centers are UMDNJ, Newark; Robert Wood Johnson University Hospital, New Brunswick and Cooper Hospital in Camden, which are all Level I trauma facilities.  The Level II trauma facilities include Hackensack University Medical Center, Hackensack; St. Joseph’s Hospital and Medical Center, Paterson; Jersey City Medical Center, Jersey City; Morristown Memorial Hospital, Morristown; Capital Health Systems at Fuld, Trenton; Jersey Shore Medical Center, Neptune and AtlantiCare Regional Medical Center, Atlantic City.

 

Most often, trauma activation occurs out in the field, when EMS personnel decide trauma activation is appropriate.  EMS personnel assess the physiology and anatomy of the injury as well as the circumstances of the injury.  If they believe it is necessary to activate the hospital’s trauma team, EMS will radio ahead for trauma activation.

 

Under current PIP/No Fault regulations, trauma services are defined as

 

[T]he care provided in the Level I or Level II trauma hospital to patients whose arrival requires trauma center activation.  It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activation or outpatient visits after a patient who has received trauma care is discharged from acute care.

 

The regulations also state that the physician fee schedule rates “shall not apply to trauma services at Level I and Level II trauma hospitals” and that  “[b]ills for services subject to the trauma services exemption shall use the modifier ‘–TS’. “

 

The above provision requiring use of the “TS” modifier applies to the physicians who render the trauma services at the trauma center. It is imperative that the trauma physicians use the “TS” modifier when billing for their trauma services. If not, they are likely to be paid at the physician fee schedule rates, which are substantially less.

 

It is important to keep in mind that this regulation has nothing to do with the trauma center’s facility charges.  The trauma hospital itself, like all other hospital ER treatment in both trauma and non-trauma facilities, is entitled to UCR (usual and customary charges) for its ER services. This is true despite the efforts of some carriers to pay some or all of the services rendered as part of ER treatment at rates less than the hospital’s UCR.

 

The Importance of the Trauma Services “TS” Modifier