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Friday, May 27, 2016

Keeping Insurance Payments Flowing | Callagy Law

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.

Billing insurance companies and collecting what you are entitled to collect can be a difficult process for medical providers. There are inevitably coverage issues, difficulties with navigating the ambiguities of policies, correct coding problems, and carriers will look for any discrepancy as a way to avoid payment. Below are a few tips to help overcome or at least alleviate some of these issues.

Let’s begin with coding. Employing a certified coder is a start. It is best these days to hire a professional, who will stay educated on the latest coding practices and information, rather than simply someone who has general knowledge. Coding has grown and continues to grow more and more complicated. A certified coder reviewing the National Correct Coding Initiative (NCCI) tables will ensure that bundling errors do not hold up payments. A professional coder can navigate the labyrinth of codes so as to limit the carriers’ ability to delay payments for coding deficiencies.

Insurance policies too can be problematic. Whenever possible a medical provider should obtain as much information about the insurance policy relevant to the treatment as possible. This might mean the declaration page of an automobile policy or the health benefit plan description for a commercial insurance patient. Knowledge of the policies and plans will help reduce, if not, eliminate unknown coverage pitfalls, and provide a better knowledge base of likely reimbursement levels. Too often providers render services having little or no real knowledge as to what the reimbursement levels will be or whether or not they are even likely to be reimbursed.

The medical documentation also can raise issues. A medical provider must make sure the supporting documentation matches the diagnosis codes, and should be very specific. It is self defeating to be cavalier about explaining the need for and the medical necessity of all aspects of the treatment. It is important to be aware of codes that need specific explanations for payment and ensure your documentation has the necessary explanations.

Finally, confronting denials as and when they happen, as well as having a competent and aggressive legal time at your disposal, will pay big dividends. You need collection personnel with tenacity and organization skills to pursue relentlessly the frequent follow up calls that are necessary. Knowing payer systems and rules and asking the right questions of claims adjusters is also important.

These are some simple suggestions to combat the revenue roller coaster many providers face. As a liaison for Callagy Law, I have seen some of my providers struggle with insurance payments, and these basic steps can help alleviate that struggle.

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:

Keeping Insurance Payments Flowing | Callagy Law

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

Tuesday, January 12, 2016

MAKING NO-FAULT NO PROBLEM | Callagy Law

A closer look into No-Fault, PIP and other important information

After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Do you have questions pertaining to reimbursement? Do you know what to do if problems arise? With articles written by Callagy Law’s law team, this blog will focus on many common questions and concerns surrounding legal matters which can arise in the field of healthcare law.

Car accidents can be overwhelming, one minute you’re on your way to work, the next minute you’re sorting through medical bills and trying to determine if you have enough insurance coverage for accident related injuries. This is why an understanding of medical benefit coverage under your New Jersey automobile insurance policy is crucial.

In the New Jersey No- Fault System, a patient’s medical claims are paid under the Patient’s First Party Policy, even if the motor vehicle collision is the patient’s own fault. All personal car insurance policies in New Jersey must contain No Fault coverage. These No- Fault Benefits are known as Personal Injury Protection or “PIP.”

The benefit of the PIP System is that the determination of liability has no bearing on the Insurance Company’s responsibility to pay the insured’s medical bills, which allows for a medical provider to receive payment prior to the underlying issue of liability being resolved. Basically, this system allows a patient to receive their necessary treatment, and a doctor to receive prompt payment.

As payment is made under the patient’s own policy, it is important that owners of private vehicles make prudent decisions when choosing their PIP Policy Coverage Limits.

The State of New Jersey allows for the election of PIP coverage in lesser amounts ($150,000.00, $75,000.00, $50,000.00 or $ 15,000.00).

Ideally, every patient would be insured under a $250,000.00 PIP Policy, meaning a patient’s medical bills would be covered up to a total of $250,000.00.

However, a patient may be enticed to select a Basic Policy, which provides only limited coverage in the amount of $15,000.00. While a limited policy may seem great at first glance, as the premiums are lower, if a patient is in a significant collision, their policy may be quickly exhausted leaving the patient on the hook for thousands in medical bills.

For example, subsequent to a motor vehicle collision, a patient may be transported to a Hospital for Emergency Room Treatment; thereafter, an extended period of chiropractic care for neck/back injuries will be recommended; and the patient may be further referred for MRIs, EMGs, pain management care and even surgery, which will easily exceed $15,000.00.

Additionally, in New Jersey, an automobile owner may choose a Health Insurance Primary Policy wherein a motor owner designates his/her health insurance policy is primary for a reduced premium.

When a patient is insured under a Health Insurance Primary policy it very important that the Medical Provider bill the Patient’s Health Insurance Provider first. After a denial is received from the Health Insurance Carrier, the Medical Provider must submit the Health Insurance Denial as well as the Providers bill to the patient’s PIP Carrier for payment.

In sum, it is important for a patient to research their options and be aware of the consequence that may follow when selecting PIP coverage for a reduced amount at a lower premium.

The Team at Callagy Law hopes the information in this article was helpful in either your personal or professional life. The legal world pertains to all walks of life and more specifically, various types of healthcare providers. Callagy Law, is a multidisciplinary law firm, headquartered in Paramus, NJ owned and operated by Sean Callagy. We are committed to providing legal representation and advice to our clients at additional law offices located across the United States. Please note that the information posted here should not be used as a legal argument of defense. If you find yourself needing legal advice pertaining to your unique situation, you can contact us at here. 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:

MAKING NO-FAULT NO PROBLEM | 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

Friday, September 25, 2015

How Do Businesses Ensure Compliance When Picking Healthcare Plans?

New and existing small businesses have to consider if they will offer health insurance and if so the owner must pick the specific benefits for the company. Under the Affordable Care Act individuals and businesses have new rights and responsibilities regarding health care insurance.

The ACA has instituted new requirements involving various parts of employer-sponsored health care insurance including waiting periods, tax credits, and disclosure rules for employees. Owners and managers of small businesses should be aware of the legal requirements surrounding these regulations to ensure compliance.

Waiting Periods

Under current law, employers who offer health insurance cannot have waiting periods longer than 90 days. Employers occasionally use waiting periods before issuing health insurance to employees. These waiting periods can be to avoid providing costly health insurance to probationary employees before they are hired permanently. Alternatively, waiting periods are sometimes used for employees who are in training periods or have started on a part-time or temporary basis but are moving to a full-time role. Of course, employees must still meet other eligibility criteria in order to obtain the employer-based health insurance.

Tax Credits

For small employers, with fewer than 25 full-time equivalent employees, the Federal government may provide tax credits. Businesses that pay average wages below $50,000 and contribute 50% or more to its employees health insurance premiums, and buy insurance through the small business insurance marketplace may be eligible for the tax credits. The tax credits may equal up to 50% of the employer’s insurance premium costs.

Notably, employers do not have to provide coverage to employee dependents or to part-time employees.

Alternatively, employers who fail to meet IRS requirements with regard to offering health insurance, may face financial penalties.

Disclosures

Employers are now required to provide employees with summary of benefits documents that explain the benefits of the health insurance plan, such as what is covered and what the cost sharing between the employer and employee are under the plan. The coinsurance, copays, and deductibles for individual services as well as annual and lifetime levels are likely going to be included in the summary documents.

Insurance carriers will draft the benefit summary document, which may be based off of a standardized document for small group insurance plans or it may be customized for a particular business. Employers should familiarize themselves with the documents to ensure that they comply with the contract that the business signed with the carrier and so that they can communicate knowledgeably with employees who may have questions about benefits under the health plan.

Employers should note that they may face penalties for failing to comply with the disclosure requirement.

Contact a knowledgeable Lawyer for Assistance

Treading into the field of Federal and local regulatory law can be confusing for busy business owners. The experienced and dedicated attorneys at Callagy Law are ready to help answer your questions about forming a business or ensuring that your existing business is in compliance with the law. Contact the team here at Callagy Law today for legal guidance.

You may also be interested in these Callagy Law Blogs:

Medical Provider, Heal Thyself: Information on the Affordable Care Act

Citizens United and Hypocrisies

Is Obamacare in the Supreme Court Again?

Learn More About Callagy Law Here:

How Do Businesses Ensure Compliance When Picking Healthcare Plans?

Tuesday, August 25, 2015

Some Helpful Hints for Ancillary Service Providers

Automobile insurers often deny a medical provider’s claim under the NJ No Fault laws (PIP) on the ground that the service was not “medically necessary.” This denial can take many forms. For example, the explanation of benefits or EOB can state explicitly that reimbursement is denied for “lack of medical necessity,” or because of the result of a Medical Director Review (MDR) or Peer Advisory Review (PAR). The denial could be the result of an IME (Independent medical Examination) or a determination that the patient reached Maximum Medical Improvement or MMI. For the most part, all of these denials are for the same reason that is, the service, according to the carrier, was not medically necessary.

If and when this type of denial goes to arbitration, the clinical records become essential to the provider’s case. It is the clinical records that will form the foundation of the medical necessity argument. But if you are a provider other than the treating physician the records you have will rarely be sufficient.

For example, a surgery center normally will send with its bill the Operative Report. This is necessary to support the fact that the surgery was performed and serves as a detailed description of the nature of the surgery. The Operative Report, however, usually does not support the medical necessity of the surgery. Similarly, the anesthesia record accompanying the bill of an anesthesiologist justifies the time and nature of the anesthesia, but does not add to whether the surgery was medically necessary.

The same is true of ancillary service providers of all medical disciplines. A pharmacy will normally append the prescription to its bill. Similarly, a DME (Durable Medical Equipment) provider, an imaging center or a lab will have clinical records supporting its provision of the service, but not necessarily documentation establishing the medical necessity of the underlying treatment.

It is the treating physician’s clinical records that are necessary for establishing the medical necessity of nearly all the medical treatment. Hence, it is best for an ancillary service provider to obtain, when feasible, not simply the prescription from the treating physician, but any other clinical records the treating physician might have to justify the medical necessity of the ancillary service. The medical notes from the office visit when the prescription was written would be helpful, or the medical notes leading to the MRI, for example, would likely provide all the justification necessary to support the medical necessity of the MRI.

Often the medical necessity of the ancillary provider’s services will rise or fall with the medical necessity of the treating physician’s services, and, accordingly, it is always safer for the ancillary service provider to obtain as much of the clinical record as possible from the treating physician.

Learn More About Callagy Law Here:

Some Helpful Hints for Ancillary Service Providers