Wednesday, January 13, 2016

Section 40 Liens | 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.


Section 40 Liens


Under Section 40, a petitioner is obligated to reimburse the workers’ compensation insurance company two-thirds of whatever they paid you (temporary benefits, medical benefits and Perm benefits) less $750.00. The general theory is that an injured worker is not allowed to a “double recovery.” In Workers’ Compensation, when someone is injured on the job, the employer pays temporary disability benefits, provides medical care, and also provides permanent disability benefits based on the nature and extent of the injured worker’s permanent injuries. The employer pays this regardless of fault.  However, when there is a liable third party, the law allows the employer to seek reimbursement of a portion of the benefits that they paid out from that third party.


Specifically, Section 40 (N.J.S.A. 34:15-40) provides in pertinent part: “Where a third person is liable to the employee or his dependents for an injury or death, the existence of a right of compensation from the employer or insurance carrier under this statute shall not operate as a bar to the action of the employee or his dependents, nor be regarded as establishing a measure of damage therein. In the event that the employee or his dependents shall recover and be paid from the said third person or his insurance carrier, any sum in release or in judgment on account of his or its liability to the injured employee or his dependents, the liability of the employer under this statute thereupon shall be only such as is hereinafter in this section provided.”


In Greene v. AIG Casualty Company, A-6287-11T4 (App.Div. October 16, 2013), the only published case on this issue, the Appellate Division provided that is does not matter that the compensation case is ultimately found non-compensable: the employer still can enforce its lien rights as to prior payments made. The Court went on to state that its holding is consistent with the remedial purpose of the Act by “making benefits readily and broadly available to injured workers through a non-complicated process.” Tlumac v. High Bridge Stone, 187 N.J. 567 (2006).  The court said that this policy encourages employers to make prompt voluntary payments because it provides much needed medical and wage loss benefits to claimants while their claim is being investigated.  In addition, the court said that its decision is consistent with the policy in New Jersey against double recoveries.


Parties should be aware of the availability of Section 40 liens when defending/pursuing workers’ compensation claims as an option to avoid protracted litigation.


 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.



Section 40 Liens | Callagy 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.



 


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MAKING NO-FAULT NO PROBLEM | Callagy Law

Monday, January 11, 2016

THE REMEDY FOR DESTRUCTION OF EVIDENCE | Callagy Law

SANCTIONS AND SPOLIATION: A closer look into Making A Murderer



 


If you have found yourself (as I have) captivated by the Netflix original documentary “Making A Murder”, you certainly see the importance and value of evidence in a legal action. Evidence – or the lack thereof – can either make or break your case. For example, when police investigators “discovered” the keys for a victim in Steven Avery’s house, that was one of the most compelling pieces of physical evidence linking Steven Avery to the crimes he was charged with. What’s more, it was his DNA on those keys that was likely the most condemning evidence of all.


 


But what about the victim’s DNA? Shouldn’t the victims DNA be on her keys?


 


The answer is maybe. If the keys were found to be tampered with and Steven Avery’s DNA added to those keys, not only would that evidence potentially exonerate Steven Avery from the crimes he committed, but it would also inculpate the investigators who discovered those keys, as well as others.


 


While we allow the story of Steven Avery to unfold, we have to ask about evidence in our own cases. Most of us do not have kinds of challenges Steven Avery faced in his trials. Most of our legal concerns are limited to civil lawsuits.


 


So what remedy do we have available to us when our adversaries may have tampered with or destroyed evidence that we need to prove our case or disprove our adversary’s case in the civil context? In addition to discovery sanctions, we have additional remedies for “Spoliation of Evidence.”


 


With regard to discovery sanctions, almost each and every state has specific rules regarding the preservation and production of evidence. For example, Rule 4:23-5 of the New Jersey Court Rules provides an outline for how to obtain sanctions, including dismissal of the Complaint or suppression of an Answer and Defenses, for failure to appropriately produce evidence requested.


 


Additionally, where appropriate, a Court may enter an Order allowing the jury (or the Judge) to accept as true that the contents of a document or the state of a piece of physical evidence is what the party seeking that Order says it is. Courts have ordered adverse inferences for spoliation of evidence, especially when that conduct is found to be intentional or reckless. To obtain an adverse inference due to spoliation of evidence, the moving party must show the evidence was essential and the spoliation was the result of an intentional act or bad faith. For example, in a product’s liability case involving a defective safe guard on power tool that malfunctioned, where the defendant destroys the power tool preventing the Plaintiff from having an expert analyze it to opine that it was defective, the Plaintiff may be entitled to an Order stating that the jury can find that the power took was defective without further discussion or deliberation.


 


While these remedies may not fully cure the harm caused by the destruction of evidence, it may go a long way towards making a litigant whole after the intentional or reckless conduct that resulted in the destruction of a key piece of evidence.



 


We hope you found the information provided in this article helpful to your everyday life and business. Please free to reach out to Sean Callagy or the Callagy Law team at any time for questions you may have concerning personal and business matters. Callagy Law’s headquarters is located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of business legal practice and business coaching, if you need help with anything, please reach out to us by calling 201-261-1700 or by emailing us here. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube by clicking here.


 


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THE REMEDY FOR DESTRUCTION OF EVIDENCE | Callagy Law

Saturday, January 9, 2016

Custody Involving A Non-Parent: The Psychological Parent

An In Depth Look and Rights and Circumstances.



 


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 practice area of Family Law. Our mission is to answer any questions and give knowledge to many different aspects of these matters.



 


Contested custody and parenting time disputes between divorcing parents is, unfortunately, a common occurrence in litigated matrimonial matters.  Most people have some familiarity, either directly or indirectly, with the general notion that courts will decide custody and parenting time conflicts between parents based upon a determination of what is in the child’s best interests.  However, how much consideration is given to potential custody and parenting time disputes between a parent and a non-parent, third party?   Probably very little, yet given the ever-evolving nature of “family,” which may include unmarried cohabitants, domestic partners, step-parents, extended family members such grandparents, aunts, uncles, etc., custody and parenting time disputes between a legal parent and a third party is a very real possibility which may become a more frequent occurrence.  Fortunately, through developing case law our courts have established legal principles that have addressed such a situation, balancing intrinsic parental rights while remaining resolute in protecting the best interests of minor children.


 


A Parent’s Fundamental Right


 


A legal parent has a right to the care and custody of his or her minor child.[i]  These rights are so basic and fundamental to the parent-child relationship that they are constitutionally protected, providing a parent with the right to raise their child without government interference.[ii]  However, such rights are not absolute.  Parental rights are routinely confined and abrogated in “issues of custody, visitation, child support and myriad other aspects of domestic relations.”[iii]  The recognition that such parental rights are not absolute reflects the long-standing principal that courts in family law matters are charged with parens patriae authority, the right of the state to protect a child’s wellbeing.  Such authority permits a court to issue an order as to the care and custody of a child based upon a showing that the order is in the child’s best interests.[iv]


 


A custody dispute between legal parents is a rather straightforward, at least in terms of the legal process.  At the outset, a presumption exists that both parents are equally entitled to the care and custody of their minor child.[v]  As neither legal parent has a greater right to the care and custody of their minor child, the focus of such a dispute is fixed upon the best interests of the child.[vi]  When determining what custodial arrangement will be in the minor child’s best interests, as between the child’s legal parents, the court is required to make factual findings considering the fourteen (14) factors enumerated in N.J.S.A. 9:2-4.  While such litigation is more often than not fraught with acrimony to the great emotional and financial costs of the litigants and the minor child, the basic legal framework is uncomplicated.  The “best interests of the child” standard is applied to custody disputes between legal parents, with both parents standing on equal-footing and a statutory structure to guide attorneys and the judiciary toward a resolution.


 


Rights of A Third-Party Against A Legal Parent


 


However, when a non-parent seeks custody of a minor child over the objection of a legal parent, the same legal standards do not apply, at least not initially.  As a general principle, third parties have no legal rights to the care and custody of a minor child.  For example, through prior case law it has been clearly established that grandparents, siblings or stepparents have no “inherent” rights to custody of the child.[vii]


 


In the context of a custody dispute between a legal parent and a third party, a presumption of custody exists in favor of the legal parent.[viii]  However, that presumption can be overcome.  Importantly, the “best interest standard” applicable in custody disputes between legal parents, cannot be utilized to rebut the presumption in favor of a legal parent in a custody dispute with a third party, non-parent.[ix]  In other words, a non-parent cannot simply assert that custody should be granted to the non-parent over the legal parent based upon the “best interests of the child” standard.  In short, “strangers may not compete with fit parents on the basis that they might be a‘ better’ parent.[x]  In recognition of the fundamental right of the legal parent to the care and custody or his or her child, a higher standard is required before a third party can assert a right to custody or parenting time with a minor child.


 


The standard that controls a custody dispute between a third-party and a legal parent involves a two-step analysis.  The first step requires application of the “parental termination” standard or a finding of Aexceptional circumstances.@[xi]


 


The “parental termination” standard requires a showing by clear and convincing evidence of parental abandonment, unfitness or gross misconduct.[xii]  The Aexceptional circumstances@ category contemplates the intervention of the court in the exercise of its parens patriae power to protect a child.[xiii]  The “exceptional circumstances” inquiry is the proverbial “catchall” category which permits a court to act in circumstances which do not rise to the level of abandonment, unfitness or gross misconduct (the “parental termination” standard).  However, as it was noted in Watkins v. Nelson, the “exceptional circumstances” inquiry is not the same as the best interests inquiry, stating


 


A significant difference between the child’s best interests test and the parental termination or “exceptional circumstances” standard is that the former does not always require proof of harm to the child.  In contrast, the latter always requires proof of serious physical or psychological harm or a substantial likelihood of such harm.[xiv]


 


In fact, as the focus of the “exceptional circumstances” standard is solely on the possibility of harm to the child, “exceptional circumstances” does not even require a showing that the legal parent is unfit.[xv]  Even if a legal parent is “deemed to be a fit parent,” a showing of “exceptional circumstances” can rebut the presumption in favor of a legal parent in a custody dispute with a third party.[xvi]  It is the probability of serious psychological harm to child, not the parent’s unfitness that may deprive a parent of custody.[xvii]


 


“Exceptional Circumstances”: The Psychological Parent


 


Within the category of Aexceptional circumstances@ is the concept known as Apsychological parent.@  The idea of a “psychological parent” grew out of our Supreme Court decision Sorentino v. Family & Children’s Soc. Of Elizabeth which recognized that there is a “serious potential for psychological harm to young children if they are removed from a foster home where they had lived and been nurtured during their early years.[xviii]  It is that “possibility of serious psychological harm to the child…which transcends all other considerations.”[xix]


 


A “psychological parent” is the legal term utilized when a third party has stepped in to assume the role of the legal parent who has been unable or unwilling to undertake the obligations of parenthood.[xx]  As it was held in V.C. v. M.J.B.,


 


at the heart of the psychological parent cases is a recognition that children have a strong interest in maintaining the ties that connect them to adults who love and provide for them.  That interest, for constitutional as well as social purposes, lies in the emotional bonds that develop between family members as a result of shared daily life.[xxi]


 


To successfully be recognized as a psychological parent and rebut the presumption in favor of the legal parent, the third party must satisfy the four (4) prong test established in V.C. v. M.J.B.   These four essential requirements are designed “to evaluate whether a third party has become a ‘psychological parent’ to a child of a fit and involved legal parent, and thus has standing to bring a custody suit.”[xxii]  However, the Supreme Court further held that establishing psychological parenthood is not an easy task and the standards “should be construed and scrupulously applied in order to protect the legal parent-child relationship.”[xxiii]


 


First, the legal parent must have consented to and fostered the relationship between the third party and the child.  Importantly, consent to create the psychological bond need not be explicit.[xxiv]  A legal parent who is voluntarily absent from the child, either physically or emotionally, or is incapable of performing parental duties may, by that action, consent to and foster a parent-like relationship between the child and a third party.[xxv]  Essentially, the legal parent is voluntarily and knowingly conveying to the third party parental authority that the third party would not otherwise warrant.  Moreover, without such a requirement, a paid nanny or babysitter could theoretically qualify for parental status.[xxvi]  Thus, this first prong makes the legal parent a participant in the creation of the bond and once created, the third party=s status as a psychological parent cannot be unilaterally terminated by the legal parent.[xxvii]


 


Moreover, consent is only needed from one legal parent.[xxviii]  In the case of K.A.F. v. D.L.M., the legal parents contested the application for “psychological parent” status by the child’s step-parent asserting that both legal parents must consent to the relationship between the third party and the child.  The Appellate Court quickly dispatched with this argument finding that such a requirement would subvert the “fundamental policy” of preventing serious psychological harm to the child “where one of the child’s legal parents colorably claims lack of consent, in circumstances where the other legal parent has consented.”[xxix]  If the consent requirement mandated consent of both legal parents, “a court would be powerless to avert harm to a child through the severance of the child’s parental bond with a third party.”[xxx]


 


Second, the third party must have actually lived with the child in the same household in a “family setting.”[xxxi]  In the matter of A.F. v. D.L.P., the Appellate Court found that the plaintiff and defendant concealed their romantic relationship from family and friends, concluding that “if the parties did not hold themselves out to the world at large as a family unit, how then can a court conclude that plaintiff lived with defendant’s child as part of a family unit, thereby satisfying the second prong of the V.C. test.”[xxxii]


 


The third prong requires the third party to have actually functioned as a responsible parent and assumed the obligations of parenthood.  Evidence of the third party taking on significant responsibilities for the child’s care, education and development will satisfy this prong.  Examples such as the third party providing clothing and shelter for the child without the expectation of reimbursement; taking the child to the doctor when the child is ill; accompanying the child to extra-curricular activities; participating in the child’s school activities; and, sharing in the child’s milestones such as birthdays, holidays, vacation, etc., support a finding that the third party has actually functioned as a parent and assumed the obligations of parenthood.[xxxiii]


 


Finally, to achieve the status of “psychological parent,” a third party must establish that a parental-bond has been forged between the third party and the child.  The Supreme Court in V.C. v. M.L.B. found this to be “the most important factor” which will generally require expert testimony.[xxxiv]


 


The Appellate Court in P.B. v. T.H. addressed this fourth prong and the evidence to support the establishment of parental-bond by quoting testimony from the trial court’s summary regarding the relationship between the child and the third party, stating


 


She’s her mom, she’s the one [the child] turns to, the one she looks for if she falls down and gets hurt, the one she goes to get support.  They have a very loving relationship; they love each other very much…not only mother daughter, but also friends, someone that you could talk to, that you can express your feelings to, that you can share your ideas with.[xxxv]


 


Addressing this prong requires an inquiry into not only the third party’s role, but the child’s emotional attachment to the third party.  Establishing that the child relies upon the third party for emotional support and turns to the third party for comfort in times of sadness; for protection in times of insecurity; for support in times of distress and uncertainty; and, for companionship in times of joy and happiness, will satisfy the forth prong of the “psychological parent” standard.  It is establishing through testimony and expert analysis that the third party is a parent in the eyes of the child.


 


The Rights of a Psychological Parent


 


So, what does it mean to achieve the status of “psychological parent?”  If the Aexceptional circumstances” prong is satisfied, the second step requires the court to decide whether awarding custody to the third party would promote the best interests of the child.[xxxvi]  If a third party achieves the status of “psychological parent,” thereby satisfying the “exceptional circumstances” requirement, he or she then stands in parity with the legal parent.[xxxvii]  Custody and parenting time issues between the “psychological parent” and the legal parent are then to be determined utilizing the “best interests” standard and a weighting of the factors set forth in N.J.S.A. 9:2-4.


 


However, the legal parent’s status is a significant factor in the best interests analysis, so much so, that when the evidence concerning the child’s best interests between the legal parent and the psychological parent is in equipoise, custody will be awarded to the legal parent.[xxxviii]  In other words, if the child’s best interests will equally served in both the legal parent’s custody and the psychological parent’s custody, the legal parent will be awarded custody.  This result reflects the superior, fundamental and constitutionally protected rights of legal parents to the care and custody of their children.  Yet, and again, the courts are ever committed to protecting the best interests of the minor child.  So, despite the mandate that a legal parent will be awarded custody in situations when the legal parent and psychological parent are in equipoise, parenting time between the psychological parent and the child “will be the presumptive rule, as would be the case if two natural parents were in conflict.”[xxxix]


 


Importantly, the process in a contested matter from establishing “psychological parenthood” to a final custody/parenting time determination is a difficult and arduous process, both emotionally and financially.  When a material factual dispute exists as to the status of a third party as a “psychological parent,” the court will be required to conduct a hearing, take testimony of witness, including expert testimony from mental health professionals, to first determine if the third party is a “psychological parent.”  If the third party is deemed a “psychological parent” and the matter remains contested, the court will be then be required to determine what custody and parenting time arrangement will serve the child’s best interests, again involving testimony, potentially from additional experts, and evidence related to the factors set forth in N.J.S.A. 9:2-4.  The emotional and financial toll on the litigants, the child, the attorneys and the court through the process is substantial.  As with any custody decision, even involving a third party, the parties reaching their own decision, rather than relying upon the court to make such a decision, often times provides a greater service to the child’s best interests then any decision rendered by a court.


 


Conclusion


 


The law, like family structure, is an ever evolving and changing process adaptable to the many circumstances and situations that confront our society.  Family situations involving domestic partners, step-parents, unmarried cohabitants, extended family, etc., are prevalent giving rise to the potential establishment of a parent-child relationship between a child and a third party.  The emergence of parental bonds between a third party and a child touches upon fundamental rights of parents and the most basic function of our judicial system, to protect the emotional and physical well being of minor children.  Fortunately, New Jersey courts have struck a balance between parental rights and the psychological well being of children which serves both interests and provides those involved in such situations with a road map toward resolution.



 


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[i] V.C. v. M.J.B., 163 N.J. 200 (2000); Watkins v. Nelson, 163 N.J. 235, 245 (2000).


[ii] Watkins v. Nelson, supra; Moriarty v. Bradt, 177 N.J. 84, 101 (2003) certif.. denied, 540 U.S. 1177, 124 S. Ct. 1408 (2004)(natural parent’s right to the care, custody and control of his or her child is a fundamental liberty interest protected by the Due Process Clause of the Fourteenth Amendment to the United States Constitution).


[iii] In re Adoption of Child by W.P., 163 N.J. 158, 195 (2000).


[iv] V.C. v. M.J.B., supra at 227.


[v] N.J.S.A. 9:2-4.


[vi] Kinsella v. Kinsella, 150 N.J. 276, 317-318 (1997).


[vii] Watkins, supra at 245.


[viii] Id at 253.


[ix] Id at 237.


[x] Id. at 254-255; P.B. v. T.H., 370 N.J. Super. 586, 598 (App. Div. 2004)


[xi] Id at 246; V.C. v. M.J.B., supra at 219;


[xii] Watkins, supra at 246; K.A.F. v. D.L.M. 437 N.J. Super. 123, 134 (App. Div. 2014).


[xiii] Sorentino v. Family & Children’s Soc. of Elizabeth, 72 N.J. 127, 132 (1976).


[xiv] Watkins, supra at 248.


[xv] V.C. v. M.J.B., supra at 219.


[xvi] Watkins, supra 246-248.


[xvii] Ibid.


[xviii] Sorentino v. Family & Children’s Soc. Of Elizabeth, surpa at 132; Zack v. Fiebert, 235 N.J. Super. 424, 430 (App. Div. 1995);


[xix] Ibid.


[xx] Ibid.


[xxi] Id. at 221, citing Smith v. Organization of Foster Families for Equality and Reform, 431 U.S. 816, 844 (1977); see also K.A.F. v. D.L.M., supra at 133.


[xxii] P.B. v. T.H., supra at 595.


[xxiii] V.C. v. M.J.B., supra at 230.


[xxiv] K.A.F. v. D.L.M., supra at 139.


[xxv] V.C. v. M.J.B., supra at 233 n.6.; see also P.B. v. T.H., supra at 598.


[xxvi] See A.F. v. D.L.P., 339 N.J. Super. 312, 322 (App. Div. 2001).


[xxvii] V.C. v. M.J.B., supra at 224-225(end of relationship between legal parent and third party does not end the bond that the legal parent fostered and that actually developed between the child and the psychological parent).


[xxviii] K.A.F. v. D.L.M., supra at 135.


[xxix] Ibid.


[xxx] Ibid.


[xxxi] A.F. v. D.L.P., supra at 323.


[xxxii] Ibid.


[xxxiii] P.B. v. T.H., supra at 603.


[xxxiv] V.C. v. M.L.B., supra at 226.


[xxxv] P.B. v. T.H., supra at 604.


[xxxvi] Watkins, supra at 254.


[xxxvii] V.C. v, M.L.B., supra 227.


[xxxviii] Id. at 228.


[xxxix] Ibid.



Custody Involving A Non-Parent: The Psychological Parent

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.



 


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Decision Point Review Plans and Their Significance

Wednesday, January 6, 2016

Section 20 Settlements | 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.



 


 Section 20 Settlements


 


According to N.J.S.A. 34:15-20, the parties to a workers’ compensation claim petition may settle the claim where (1) jurisdiction, liability, causality and/or dependency are disputed; (2) the parties wish to resolve the claim with a lump sum settlement; (3) the parties consent to the settlement; (4) the parties are represented by Counsel; and (5) a judge of compensation determines that the settlement is fair and just under the circumstances.  Notably, once the settlement is approved, it shall have the force and effect of a dismissal of the claim petition and shall be binding on the employee and employee’s dependants.  Id. Such settlements are commonly referred to as “Section 20 Settlements” based on N.J.S.A. 34:15-20.  In relevant part, N.J.S.A. 34:15-20 states:


34:15-20. Dispute; submission to division; order approving settlement.


…


After a petition for compensation or dependency claims has been filed, seeking compensation by reason of accident, injury or occupational disease of any employee, and when the petitioner is represented by an attorney of the State of New Jersey, and when it shall appear that the issue or issues involve the question of jurisdiction, liability, causal relationship or dependency of the petitioner under this chapter, and the petitioner and the respondent are desirous of entering into a lump-sum settlement of the controversy, a judge of compensation may with the consent of the parties, after considering the testimony of the petitioner and other witnesses, together with any stipulation of the parties, and after such judge of compensation has determined that such settlement is fair and just under all the circumstances, enter “an order approving settlement.” Such settlement, when so approved, notwithstanding any other provisions of this chapter, shall have the force and effect of a dismissal of the claim petition and shall be final and conclusive upon the employee and the employee’s dependents, and shall be a complete surrender of any right to compensation or other benefits arising out of such claim under the statute.


Parties should be aware of the availability of Section 20 settlements when defending/pursuing workers’ compensation claims as an option to avoid protracted litigation. Indeed, Section 20 Settlements are particularly appealing where the costs of defending against or pursing a claim are not sensible in light of the value claim. However, when entering into a Section 20 settlement, the parties should be mindful of the fact that such a settlement will likely bar any subsequent claims by the petitioner and such employee’s dependants.



 


 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.



 


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Section 20 Settlements | 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:


Avvo


Blog


Facebook


YouTube


Pinterest


Indeed


Yelp


LawNearMe


Wikipedia


Website



Can PPOs and PIP Coexist? | Callagy Law