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Friday, January 22, 2016

Is Ted Cruz “Born To Run?” | Callagy Law

The Controversy over Ted Cruz’s Eligibility for President and the Vicissitudes of Constitutional 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.

Whatever you may think about his politics or personality, Donald Trump has injected an interesting debate into the election year discourse. Although it may have been a mere distraction tactic, Trump’s questioning whether presidential candidate Senator Ted Cruz is constitutionally eligible to serve as President has generated countless headlines in the news media and has prompted the country’s foremost legal scholars to enter the fray. And, as is often the case, the only consensus appears to be that the answer isn’t clear cut. Why that is reveals a telling feature of Constitutional law.

First, background: Ted Cruz was born in Canada in 1970. His father was a Cuban-born, Canadian citizen and his mother was an American-born U.S. citizen. He held citizenship from both nations until he voluntarily renounced his Canadian citizenship in 2014.

According to Article II, Section 1, Clause 5 of the Constitution, among the requirements to be eligible to serve as President is that one must be a “natural born citizen.” The phrase sounds simple enough, but what it actually means is anything but.

On one side you have those who argue that, if the word “natural” is to have any meaning at all, the phrase must mean more than merely someone who is a citizen at birth. Otherwise, why not just say “born citizen”? Could the founders have been so carelessly verbose?

Evidence to support this view comes from the founders’ purported own understanding of the word “natural.” At the time it meant something not created by statute—i.e., not a law enacted by Congress (or, in pre-revolutionary times, the British Parliament)—as in “natural rights,” which were part of the judge-made common law stretching back through the history of England to the Magna Carta and incorporated into early American law.

At common law, “natural born” meant born within the nation’s sovereign territory. The only exception was for those born to public officials serving the nation in a foreign land—for example, the child of a diplomat serving in France. So, the argument goes, by including the word “natural” in “natural born citizen” the Founders meant that only those born within the sovereign territory of the United States or to public officials serving abroad could become President. Under this theory, then, Ted Cruz is ineligible.

On the other side you have those who argue that, because the Constitution gives Congress the authority to determine the requirements of citizenship (Article I, Section 8), a “natural born citizen” is whatever Congress says it is at any given time.

In 1970, when Cruz was born, section 301 of the Immigration and Nationality Act, which is still in effect today, provided that “a person born outside the geographical limits of the United States. . . of parents one of whom is an alien, and the other a citizen of the United States who, prior to the birth of such person, was physically present in the United States . . . for . . . not less than five years, at least two of which were after attaining the age of fourteen years” is a citizen of the United States. Under this theory, then, Ted Cruz could be the next Commander in Chief – if he gets elected, of course.

Brilliant legal minds are scattered on both sides of the debate. Harvard law professors disagree with each other while two former solicitors general – one appointed by George W. Bush, the other by Barack Obama – completely agree with one another. It’s quite a mess. But what it tells us is that the essence of the law, and Constitutional law in particular, is debate itself.

It is a debate the Supreme Court will enter only if Senator Cruz is threatened with government action against him because of the issue—for example, if a state official, believing Cruz to be ineligible on account of his birthplace, refuses to put Cruz’s name on a ballot. One recent lawsuit filed by a retired Texas federal prosecutor, suing on behalf of all registered voters, will almost certainly be dismissed for lack of standing. Until the Supreme Court decides the issue, it will continue to be a debate more academic than practical.

Regardless, the debate is important because it reveals the nebulous nature of Constitutional law and the enormous power of the Supreme Court—deciding the meaning of words written hundreds of years ago to determine who may and may not lead this country.

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.

Learn More About Callagy Law Here:

Is Ted Cruz “Born To Run?” | Callagy Law

Thursday, January 21, 2016

Effects of PPACA on Workers’ Compensation

A closer look into the Universal Healthcare System

This week, Democratic Presidential Candidate Bernie Sanders unveiled his universal healthcare plan aimed to guarantee healthcare as a fundamental right for every American. The Sanders healthcare strategy is to expand medicare and creating a single payer health care system for every American. Sanders, a supporter of the Patient Protection and Affordable Care Act (PPACA), does not feel the PPACA goes far enough to provide the nation with adequate healthcare coverage. To fund the cost of the plan, Sanders plans to increase the top marginal tax rate to 52% for income over ten million dollars and by imposing a 2.2% flat tax on all income beyond the standard deduction.

The PPACA, also known as “Obamacare”, was enacted in 2010. Obamacare had no direct affect on the United States’ workers’ compensation system. The PPACA is targeted at health insurance, which provides coverage for non-work injuries and illness. The act also does not make any changes to the control states have over their workers’ compensation system. However, some experts believe that the PPACA will have long term indirect effects on the workers’ compensation system. The first of these effects is a decrease in fraudulent workers’ compensation claims. The reasoning behind this effect is that as health care is made more available there will be less motivation to cheat the workers’ compensation system into paying for non-work related injuries. A second effect is that in theory a healthier US population would be less likely to suffer work injuries and, thus, the number of workers’ compensation claims would decrease. Additionally, those workers that do file workers’ compensation claims would need less treatment due to improved overall health. A final and concerning indirect effect is that an increased in the number of insured individuals may overwhelm the healthcare industry and cause greater delays in treatment.

According to a report by the Centers for Disease Control and Prevention there were roughly 11.4 million uninsured Americans as of 2014. Senator Sanders’s “Medicare for All” plan would cover these individuals. Like the PPACA, there seems to be no mention of any direct effects on workers’ compensation but due to the additional number of participants in the system, the indirect effects are likely to be magnified.

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Effects of PPACA on Workers’ Compensation

Tuesday, January 19, 2016

Reimbursement For Fewer Than All CPT Codes Billed | Callagy Law

IS THIS PERMISSIBLE UNDER NEW JERSEY PIP REGULATIONS?

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.

Let’s say someone injured their right knee in a motor vehicle accident and underwent physical therapy but still had residual pain and deficit of function. The patient went to an orthopedist, who recommended and performed a right knee arthroscopic surgery. The doctor billed two CPT arthroscopic knee surgery codes, Codes 29875 (limited synovectomy) and CPT Code 29877 (debridement/shaving of articular cartilage, or chondroplasty). The Operative Report even shows both these procedures were performed as part of the knee surgery. Why, then, did the PIP insurer only reimburse the doctor for treatment under CPT Code 29875? Isn’t the doctor entitled to separate reimbursement for the procedures performed under CPT Code 29877? The short answer is no, as discussed below.

Reimbursement under New Jersey PIP law is generally governed by N.J.A.C. 11:3-29.4, “Application of medical fee schedules.” This regulation states providers and payors shall use the National Correct Coding Initiative (NCCI) Edits as updated by CMS (The Centers for Medicare & Medicaid Services.) Under the NCCI Edits, one CPT Code may be considered bundled into another Code, and payment will only be due for the one Code. Other times, a modifier may be required in the billing of the second Code and documentation to show the second procedure was “over and above” the treatment provided under the first Code. Other times, Codes are listed but there is no conflict and no barrier (from this perspective) to separate reimbursement for both Codes.

More specifically, the governing PIP regulation, N.J.A.C. 11:3-29.4 (g)(1) states:

Artificially separating or partitioning what is inherently one total procedure into subparts that are integral to the whole for the purpose of increasing medical fees is prohibited. Such practice is commonly referred to as “unbundling” or “fragmented” billing. Providers and payors shall use the National Correct Coding Initiative (NCCI) Edits, incorporated herein by reference, as updated quarterly by CMS and available at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used. For more information on the criteria for the use of modifiers, see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above.

Therefore, to determine if a medical provider is entitled to separate reimbursement for multiple CPT Codes, the NCCI Edits must be reviewed. Information on NCCI Edits may be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.

A pair of codes must be looked up to determine if there is an NCCI edit. If the codes do appear on the list of NCCI edits, check if the edit was in effect the date the treatment was performed. There is a column for “effective date,” as well as “deletion date.”

Let’s assume your pair of codes are on the NCCI edit list and the edit was in effect when the treatment was provided. The next issue is whether the edit is designated a “0”, a “1” or a “9.” If your pair has a “9” designation, there is no conflict. If your pair has a “0” designation, you are not entitled to separate reimbursement for both codes. If, however, your pair has a “1” designation, you may be entitled to separate reimbursement if the conditions for separate reimbursement are met. The conditions are billing with a proper modifier (often a -59 modifier) and having the proper documentation to support separate reimbursement. The type of documentation generally required for separate reimbursement is proof the second treatment was “over and above” or “separate and distinct” from the treatment provided under the first code.

In our example above, CPT Code 29877 is not separately reimbursable from CPT Code 29875. The NCCI edit conflict is set forth below, and contains a designation of “0,” meaning no modifier and documentation will overcome the bundled designation of the second code.

Column 1

Column 2

* = In existence prior to 1996

Effective Date

Deletion Date

*=no data

Modifier

0=not allowed

1=allowed

9=not applicable

29875

29877

20030401

An example of a “1” designation is billing for an arthroscopic shoulder surgery under CPT Code 29827 (rotator cuff repair) and 29825 (lysis and resection of adhesions). The pair of these codes has a “1” designation. Use of a -59 modifier with adequate documentation justifying the second code may result in separate reimbursement.

29827

29825

20030701

It is important to be familiar with current NCCI Edit conflicts and requirements to obtain separate reimbursement, when applicable.

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:

Reimbursement For Fewer Than All CPT Codes Billed | Callagy Law

Monday, January 18, 2016

A Closer Look into Amendments | Callagy Law

15 Million Civil Lawsuits Are Filed Each Year in the United States | More insight into amendments

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 business and commercial litigation. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

According to the latest polls, 15 million civil lawsuits are filed each year. That is one lawsuit for every twelve adults in America and one filing every two seconds. One overarching flaw that a majority of these complaints and their corresponding answers have in common is that they fail to name all the proper parties or assert all the proper claims or defenses. The mechanism to fixing these mistakes is called an amendment.

In the trial level court of New Jersey, called the Superior Court, one of the rules governing amendments is 4:9-1. Specifically this rule allows a party to amend their pleading once at any time before the opposing party responds. After a party a responds, there are then only two avenues to amend: one is by consent of the other party and the other is by leave of court which “shall be freely given in the interest of justice”

The phrase “in the interest of justice” is quite broad and may leave many readers wondering what courts will look to decide if an amendment fits into this phrase. While there a handful of factors that a court analyzes in reaching this conclusion, the overwhelming consideration is the prejudice that will be suffered by the other party if the amendment is granted.

In Keller v. Pastuch, the Plaintiff, who were husband and wife, brought suit against an automobile driver after the car the wife was riding in was struck by the Defendant. 94 N.J. Super. 499, 501 (App. Div. 1967). On the opening day of trial the defendant sought leave of court to amend his answer to include a new defense. Id. Subsequently, the court granted a mistrial and heard, later on that same day, oral arguments on whether the amendment should be granted. Id.

The plaintiffs argued that they would be substantially prejudiced due to the lateness of the defendant’s proposed amendment. Id. In response, the defendant argued that he did not know this defense was available to him until a recently conducted interview. Id. at 503. The court sided with the plaintiff and held that the defendant could have asserted the defense earlier, which in turn would have allowed the plaintiff’s to preserve their rights.

By contrast, in Sheppard v. Braun the court granted plaintiff’s motion to amend to add two new parties. No. ATL-L-1900-05, 2005 WL 2560782, at *1 (N.J. Super. Ct. Oct. 7, 2005). The plaintiff, a car accident victim, sought to add the Borgata Hotel after he recently learned that the hotel may have been serving alcoholic beverages that contributed to the accident. Id. The court summarily granted the motion, due to the fact that it was unopposed and no trial or arbitration date had been set. Id.

Thus, as a litigant it is important to act swiftly when amending a pleading, so as to ensure that the opposing party is not prejudiced and thereby causing the court to deny the amendment.

Sean Callagy, the owner and President of Callagy Law is an attorney, business coach, public speaker, and entrepreneur; and is dedicated to the personal and business growth. Please reach out to us here with any questions or comments regarding personal or business matters. We will to continue to provide daily updates with helpful information on our website and social media. Please feel free to contact Callagy Law at anytime. 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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A Closer Look into Amendments | Callagy Law

Upcoming Shortage of Physicians | Callagy Law

Difficulties Facing the American Healthcare System – What You Need To Know!

There are many difficulties facing the American healthcare system, but perhaps chief among them is a possible shortage of physicians. The Association of American Medical Colleges (AAMC) predicts that an approximate shortage of 90,000 – 130,000 physicians will occur in the US by the year 2025. There are many factors contributing to this problem, including inadequate enrollment in medical schools.

Many new allopathic (M.D. granting) and osteopathic (D.O. granting) medical schools have been established in recent years, with overall medical school enrollment expected to increase by 30% by 2019. New Jersey has recently started Cooper Medical School of Rowan University and Seton Hall School of Medicine to help meet the health care needs and many other states are following suit.

While increasing the number of medical schools would help to alleviate this shortage, perhaps a more important and overlooked issue is reduction in the fund of residency positions. A residency is a multi-year education program medical school graduates must complete before they can become practicing physicians or surgeons. In 1997, Congress capped the number of Medicare-supported residency positions. In other words, even if we add medical school graduates by increasing the number of medical schools, we will not add to the number of practicing physicians unless we also add to the number of residency training programs. A bill was introduced that would increase residency positions in 2012, but Congress has yet to act on the bill.

The AAMC urges all Americans to rally for support of this bill, and while it will not entirely fix the projected physician shortage, it seems to be a step in the right direction.

Sources

http://www.ama-assn.org/ama/pub/news/news/2015/2015-03-05-ama-applauds-congress-modernize-graduate-medical-education.page

https://www.aamc.org/newsroom/newsreleases/305476/120928.html

https://www.congress.gov/bill/112th-congress/house-bill/6562

https://www.aamc.org/newsroom/newsreleases/431036/20150430.html

Photo Credit: www.vox.com

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:

Upcoming Shortage of Physicians | Callagy Law

Thursday, January 14, 2016

Section 20 Settlements

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.

Learn More About Callagy Law Here:

Section 20 Settlements

Why Not with Sean Callagy #32 | Welcome to 2016

Why Not?! – Episode 32

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Why Not with Sean Callagy #32 | Welcome to 2016