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Friday, April 1, 2016

Decision Point Review Plans and Their Significance

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.

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.

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Decision Point Review Plans and Their Significance

Tuesday, February 16, 2016

Insurance Carriers and Adequate Notice of In-Network Provisions

Insurance Carriers must provide adequate notice of their In-Network provisions

Many insurance companies Decision Point Review plans require that a patient present to specific providers (“in network”) for certain services (ie. surgery centers, diagnostic imaging, etc.) The insurance carriers are permitted to assess an additional 30% out of network co-payment penalty if those types of services are performed at an out of network facility.

However, a 30% vendor penalty cannot be applied where proper notice was not given to the patient that he/she was to obtain services through a designated vendor, and if the specific names and contact information for the providers were not provided to the patient, as same would be in violation of N.J.A.C. 11:3-4.8(c)(2).

N.J.A.C. 11:3-4.8(c)(2) dictates:

Upon receipt of a request for PIP benefits under the policy, the insurer or its PIP vendor shall make available to the insured and the treating medical provider information about approved networks and providers in the network, including addresses and telephone numbers.

That statute informs the carriers of the procedures they must follow in order to properly asses the penalty.

First, Respondent must provide proof that its DPRP was provided to the patient. As it is within a carrier’s Decision Point Review Plan (“DPRP”) that the 30% out-of-network penalty is discussed, outlining the guidelines that must be followed in order to avoid this penalty. Without having submitted proof that the DPRP and notice of the network provisions thereof were provided to the patient, there is no proof that the patient was aware he/she would even be penalized.

In arbitration many DRPs have ruled on these issues. DRP Fabiano discussed this is a NAF award where he held, “By not providing notice and information regarding the existence of and use of the voluntary networks to the insured, I find that the respondent has failed to comply with 11:3-4.8(c)(2).” (See, NJ-1223979)

DRP Patriaco also held that where the insurance carrier did not provide sufficient evidence that the DPRP was provided to the patient and treating physician pursuant to N.J.A.C. 11:3-4.7, the provider was not required to follow the provisions of the DPRP, to prevent penalty. (See, NJ-268557) The aforementioned matter involved whether or not Claimant was required to follow provisions regarding appeals, however, this is easily translatable to the issue of a DPRP regarding vendors. Therefore, without proper notice of the out-of-network penalty, Claimant’s fees cannot be reduced by the penalty amount.

In addition to failing to notify the patient and/or provider, the carriers must also prove that the information they submitted complied with the statute which requires addresses and telephone numbers relative to its approved networks and providers.

If the Respondent’s DPRP only references a telephone number to call, and that number does not reference a list of specific in network providers and their contact information, or at the very least contain a voice prompt providing access to this information, the insurance company has not satisfied the requirements of N.J.A.C. 11:3-4.8(c)(2), and accordingly, the 30% penalty would be improper.

In another arbitration award, DRP Mundy found that Respondent’s “DPRP fails to show how the insured or treating medical provider can contact the approved network providers.” (NJ-1461388) DRP Mundy authored another award finding:

DPRP is not in compliance with N.J.A.C. 11:3-4.8(c)2 in that it fails to “make available…information about approved networks and providers in the network, including addresses and telephone numbers.” Simply providing a phone number with no direct information regarding the approved networks is not enough to satisfy this requirement.

(See NJ-1491724)

DRP Amendola also found in Claimant’s favor in a case where the letter sent to the patient did not contain all of the statutorily required information, stating:

Missing from the July 6, 2012 letter to the patient is the contact information for the approved networks. N.J.A.C. 11:3-4.8 (c) (2) states that the in network provider information must be made available to the insured and the treating doctor. Even if I were to find that the July 6, 2012 letter was sent to the patient, the letter did not include the information required by the administrative code. Proper notice, with the required information to the patient, is crucial since it is the patient ultimately responsible for payment of the penalty.

(emphasis not added)

(see NJ-1482248)

Finally, in the event that the insurance carrier initially failed to provide proper notice in their DPRP, but later sent a notice to the patient very close in time to the procedures some DRPs have found that to be insufficient.

For example, a notice sent a mere three days before the treatment was scheduled would most likely be deemed as sent to too late in time to provide sufficient notice under N.J.A.C. 11:3-4.8(c)(2). Even if such a letter was received by patient prior to the services scheduled, practically speaking, it would be too late for the patient to change the location of an already scheduled procedure. Additionally, the patient might have potentially taken off work, and would maybe even arranged for someone to watch their children. Therefore, even if a patient received the notice letter three days before their appointment, the notice provision of N.J.A.C. 11:3-4.8(c)(2) would be thwarted because the insurance carrier sent this information so far into the process. It should have been provided up front in the DPRP. DRP Ganzhorn ruled in favor of the Claimant in this exact situation in NJ0703000951217, where she found that an out-of-network penalty did not apply when notification letter was dated three days prior to date of service.

Callagy Law has been extremely successful in obtaining recovery for improperly assessed out of network penalties to our clients based on the above arguments. If your billing has been reduced due to out of network penalties, contact Callagy law for help in obtaining reimbursement.

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Insurance Carriers and Adequate Notice of In-Network Provisions

Friday, January 8, 2016

Decision Point Review Plans and Their Significance

Part 1: Pre-Certification

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.

Understanding Decision Point Review Plans or DPRP’s is critical to any medical provider who sees patients injured as a result of a motor vehicle accident (MVA). 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.

DPRP’s are filed with the state by PIP insurance carriers in order to set forth that carrier’s substantive and procedural requirements needed for a medical provider to be reimbursed by the PIP carrier. They enable carriers to not only 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.

Perhaps most importantly, DPRP’s are a tool for insurers to oversee the medical necessity of treatment. Carriers can deny approval of medical services and reduce or deny payment for medical treatment, when insurers feel the treatment does not comport with medical guidelines. Of course, these determinations are often quite subjective and can be challenged by the medical provider and firms like Callagy Law. In fact, when a medical provider disagrees with the determination, they should and must immediately appeal the denial to safeguard their interests.

Pursuant to the carrier DPRP’s, insurers are to be notified of treatment plans by treating medical providers. These notifications will be faxed to a designated fax number, established by the carrier, and will be reviewed for certification or denial within 72 hours from receipt. Along with the Attending Provider Treatment Plan Form (ATPT form), the treating provider will submit medical notes to support the requested treatment. When the requested treatment falls within medical guidelines or standards for treating that specific injury, insurers are supposed to approve the treatment, and send notice to that effect to the treating provider.

Those approvals usually come from nursing staff working for the insurer or a designated medical vendor working with the insurer. Should the nurse feel the treatment is not in line with current medical protocol, then the requested treatment will be sent to a doctor for review. The doctor reviewing the requested treatment is still held to the 72-hour rule, and if a denial or approval is not communicated within that 72 hours, the requested treatment will be considered approved. This rule is in place to ensure carriers do not hold up treatment for injured patients.

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:

Decision Point Review Plans and Their Significance

Tuesday, December 1, 2015

Failure to Cooperate – IME No Show | Callagy Law

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.

There are many times when a provider will receive a notification from the patient’s insurance company notifying them that benefits are terminated due to the patient’s failure to appear for a scheduled Independent Medical Examination (“IME”) appointment. Insurance companies, patient and providers alike have to adhere to N.J.A.C. 11:3-4.7 in regards to the scheduling of an IME however, and however should know that there are several defenses available that will negate the carrier’s denials.

No notice to provider of carrier’s plan provisions regarding IME attendance

The carrier may allege that the patient and the provider were notified of the obligation to appear for an IME via its Decision Point Review Plan (“DPRP”). (Read more about DPRP’s in thei blog post). There is a legal requirement, however, that the carrier must show that the DPRP was in fact sent to the patient and the provider by submitting letters addressed to each. N.J.A.C. §11:3-4.7(c) provides in pertinent part: “(c) A decision point review plan filing shall include the following information: [ . . . ] 3. Copies of the informational materials described in (d) below and an explanation of how the insurer will distribute information to policyholders, injured persons and providers at policy issuance, renewal and upon notification of claim” (emphasis added).

If an insurance company cannot prove that these letters were sent, the denial of benefits based on an alleged failure to cooperate will be overcome.

No proof of delivery of IME Scheduling Notices

N.J.A.C. 11:3-4.7(e)(7), provides the following, “Insurers may include in their decision point review plan a procedure for the denial or reimbursement for treatment, diagnostic testing or durable medical equipment after repeated unexcused failure to attend a scheduled physical examination. The procedure shall provide for adequate notification of the insured and the treating provider of the consequences of failure to attend the examination.” This essentially requires insurers to provide adequate notification of scheduled IMEs.

The insurance company must submit proof that correspondence was sent to the patient and the provider indicating the time and date of the IME and any receipts or confirmations of delivery of same (i.e. certified mailings). Without such correspondence, there is no tangible proof that the patient or the treating provider were sent the scheduling letters and therefore the scheduling letters cannot be used to terminate benefits, and an alleged failure to cooperate will be overcome

IMEs not timely scheduled

Additionally, N.J.A.C. 11:3-4.7(e) provides: “A physical examination of the injured party shall be conducted as follows: 1. The insurer shall notify the injured person or his or her designee that a physical examination is required to determine the medical necessity of further treatment, diagnostic test or durable medical equipment…2. The appointment for the physical examination shall be scheduled within seven calendar days of receipt of the notice.”

IME scheduling letters that set the date of the exam significantly further out than seven days have been found by certain arbitrators to have violated the statutory requirements, and have, therefore, been ruled to not be an effective means of terminating the patient’s benefits.

Draconian remedy not established

Lastly, New Jersey’s Appellate Division ruled in New Jersey Auto. Full Ins. Co. v. Jallah, 256 N.J. Super. 134,141 (App. Div. 1992) that a dismissal of an otherwise deserving claim for failure to submit to a statement should be reserved for egregious breaches, referring to the dismissal of a claim as a draconian remedy.

An insurance company’s evidence must demonstrate that the patient’s failure to appear shows that the patient was non-cooperative and egregiously breached his/her duty to cooperate and therefore warrants such a drastic remedy as denial of payment.

Without a showing of an egregious breach, some arbitrators have found that a failure to show at an IME is not sufficient to terminate the patient’s benefits.

Conclusion

If providers become aware that a carrier is seeking to examine a patient, the provider should encourage the patient to attend the examination, as such is required under the policy. If, however, the patient does not attend, there are still several possible defenses to the carrier’s eventual termination of benefits. Callagy Law has been successful at advancing each of the defenses above, depending on the circumstances of the case.

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:

Failure to Cooperate – IME No Show | Callagy Law

Tuesday, November 17, 2015

PIP ARBITRATION PRACTICE TIP | CALLAGY LAW

THE IMPORTANCE OF FILING INTERNAL APPEALS PRIOR TO FILING A DEMAND FOR ARBITRATION

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, andCommercial Insurance. We hope to have this blog shed a light on many common questions.

One of the most common defenses raised by insurance carriers as a basis to deny a medical provider’s claim for personal injury protection (“PIP”) benefits is failure to file internal appeals. Prior to filing a Demand for Arbitration on assignment from a patient, medical providers must comply with the PIP insurer’s internal appeal process. Thus, it is of critical importance for medical providers to abide by the PIP insurer’s internal appeal requirements, which can be found in the insurer’s Decision Point Review Plan (“DPRP”). Insurers generally forward their DPRP to treating medical providers after receipt of the treating provider’s 21 day notice letter.

The controlling regulation , N.J.A.C. 11:3-4.7(d)(8), requires that informational materials for policyholders, injured persons and treating medical providers shall include particular information including an explanation of the alternatives available to the provider if reimbursement for a proposed treatment, diagnostic test or durable medical requirement is denied or modified, including the insurer’s internal appeal process and how to use it. If the insurer does not have proof that it sent a copy of its DPRP to the patient and/or treating medical provider, it may lose the right to assert the defense of failure to file an internal appeal based on the fact that there was a lack of notice to the patient and/or treating medical provider of the internal appeals process.

It is important to review the PIP insurer’s internal appeals process since carriers have different requirements regarding whether both a 1^st and 2^nd level internal appeal must be filed, the deadlines for filing same and whether the appeal can be faxed or must be sent by regular mail or certified mail to a specific address listed in the DPRP. Medical providers must retain written proof that they forwarded the internal appeal(s) in compliance with the DPRP requirements, which can be by facsimile confirmation or certified mail return receipt.

There are two different types of internal appeals: (1) an appeal of an adverse determination based on lack of medical necessity and (2) an appeal of non-payments or under-payments, which can be based upon any of the following grounds:

Causation

Improper coding or down-coding of services

Usual, customary and reasonable rates

Lack of documentation

Coverage issues such as lack of cooperation

Improper pre-certification penalties.

Medical providers should keep in mind the importance of listing all potential bases of their appeal since the information listed on the appeal governs and may limit the arguments that may be raised in a later PIP arbitration proceeding.

In sum, medical providers should pay close attention to a PIP insurer’s DPRP plan’s internal appeal requirements. When an insurer denies treatment, a medical provider should promptly file an internal appeal of the denial to protect its rights to proceed to PIP arbitration.

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PIP ARBITRATION PRACTICE TIP | CALLAGY LAW