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Friday, April 29, 2016

Are MRI’s Reimbursable | Callagy Law

MRIs can be performed within five days of the insured event under certain circumstances

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.

Magnetic resonance imaging (MRI) is a test not normally performed within five days of the insured event. As a result, some insurance carriers will attempt to argue that these tests are not medically necessary and therefore, not reimbursable. However, clinically supported indication of neurological gross motor deficits, incontinence or acute nerve root compression with neurologic symptoms may justify MRI testing during the acute phase immediately post injury

In N.J. Coal. of Health Care v. Dept. of Banking & Ins., 323 N.J. Super. 207 (App. Div. 1999) at 247, the Court found that “[f]or cervical, thoracic and lumbar-sacral spine injuries, the first step in treating a patient involves, and logically so, a clinical evaluation by the appropriate health-care provider. Such an evaluation may include x-rays, CT scan, and an MRI, if necessary.”

Moreover, N.J.A.C. 11:3-4.5 (b) (5) states that these tests have been determined to have value in the evaluation of injuries, the diagnosis and development of a treatment plan for persons injured in a covered accident, when medically necessary and consistent with clinically supported findings, when used in accordance with the guidelines contained in the American College of Radiology, Appropriateness Criteria to evaluate injuries in numerous parts of the body, particularly the assessment of nerve root compression and/or motor loss.

The MRI test uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. The area of the body being studied is placed inside a special machine that contains a strong magnet. Pictures from an MRI scan are digital images that can be saved and stored on a computer for more study. The images also can be reviewed remotely, such as in a clinic or an operating room. In some cases, contrast material may be used during the MRI scan to show certain structures more clearly.

In many cases, MRI gives different information about structures in the body than can be seen with an X-ray, ultrasound, or computed tomography (CT) scan. MRI also may show problems that cannot be seen with other imaging methods.

According to the American College of Radiology, MRI testing should be reserved for cases of known or suspected soft tissue injuries such as disc herniations, ligament tears, epidural hematoma and spinal cord edema or hematoma, especially in the presence of a neurological deficit.

In Care Paths 1 and 5 for soft tissue injuries to the cervical spine and lumbar-sacral spine, respectively, though, an MRI may be administered if there are abnormal neurologic findings (i.e.: radiculopathy) and typically following a course of four weeks conservative treatment with no improvement in symptoms. In Care Paths 2 and 6 for soft tissue injuries to the cervical spine and lumbar-sacral spine with symptoms of radiculopathy, a minimum of two weeks conservative treatment without improvement in symptoms is recommended before administering an MRI.

As the MRI testing is appropriate during the clinical and diagnostic evaluation of injuries to the cervical and lumbar spine, especially if there are abnormal neurologic findings; these tests are in fact reimbursable if performed within five days of the insured event.

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:

Are MRI’s Reimbursable | Callagy Law

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:

Wednesday, December 16, 2015

Must Know Info For Medical Providers | Callagy Law

Providers Making The Most Out of Recovery

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.

Medical Providers are busy people, as are their patients. Doctors are (and should be) more preoccupied with treating their patients and increasing the quality of their lives, rather than dealing with administrative paperwork. That is why medical providers rely upon their office staff for assistance. In the hustle and bustle of day to day treatment of patients, some doctors pay less and less attention to the underlying business aspects of their practice. However, it is important that medical providers themselves stay informed as to how to optimally recover money for the treatment and procedures they provide.

Insurance carriers will deny a claim for many reasons – need for additional records, amended bills, etc. It could take over a year in some cases for a medical provider to be reimbursed. Obviously, this has a detrimental impact on a medical providers’ expected cash flow.

So what can a medical provider do to overcome these denials and delays? A medical provider should be aware which procedures are covered by the patient’s insurance policy. More information is also available on http://www.cms.gov and/or on the insurance carrier’s website. For instance, Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant, nurse practitioner or clinical nurse specialist. A medical provider should try to get pre-authorization from the insurance carrier, while also being mindful of other denial issues, such as a perceived lack of medical necessity.

If a medical provider wants to proceed on a non-covered procedure, they should be aware in advance that the insurance carrier will deny payment. If a medical provider is considering charging the patient, they should be sure to have an agreement with the patient in writing prior to surgery. Billing after surgery is not always the best business policy for medical providers and may even be in violation of a contract if they are in-network with particular insurance carriers. Moreover, balance billing the patient in most cases is not permitted in PIP (Personal Injury Protection) and Medical Provider Workers’ Compensation claims.

The medical provider should specific services he or she performs in its operative report, ensuring that every CPT code in the bill correlates with the operative report. Insurance carriers will usually reference the operative report to confirm this information and will sometimes request the assistant surgeon’s medical records. A medical provider should be prepared to get involved and file multiple appeals in order to be reimbursed.

However, the most important step in the entire process occurs in the pre-surgery stage– don’t be afraid to communicate with the insurance carriers about what documents and information they need to efficiently and effectively process the claim, what procedures are authorized, and what is the expected reimbursement rate. Be sure to thoroughly document these conversations, or better yet, get it in writing.

Of course, it is very important to hire a law firm to review claims, handle appeals and proceed to litigation, as doctors are very busy with treating their patients – which is what matters most.

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:

Must Know Info For Medical Providers | Callagy Law