If you are a medical professional who sees a significant number of patients injured in automobile accidents, you are forced to deal with claim payment from automobile insurance company.  If you are a chiropractor, pain doctor, work in a level 1 trauma center, work in a surgery or MRI center, or an orthopod, you may find a lot of request for payment either being denied altogether or paid in less than the full amount.

Once the insurer's appeal process is exhausted, New Jersey and New York state law allows you to file an arbitration to settle the case.  We are proficient in handling these cases for your practice.  Our staff will help organize your practice and ready your files for optimum results from the arbitration process.  We employ the latest of virtual and tracking technologies to streamline the process, keeping you informed and (more importantly) obtaining results for you as quickly as possible.

Let's face it.  When it comes to running a successful medical practice, cash flow is 90% of the battle.  For a free consultation and practice evaluation, please contact us.  We will analyze files and determine your possible chance of success in each arbitration.

ADDITIONAL INFORMATION ABOUT NJ PIP

Every insurance policy issued on an automobile registered/garaged in New Jersey provides these benefits which include coverage for medical expenses and lost wages. When a person is involved in an accident while driving or occupying a car, the insurer of the vehicle owned by that person (or, if the person does not own a car but resides with a relative who owns a car, the insurer of the relative’s car), even if that car is not involved in the accident, pays for the reasonable and necessary medical care to treat that person’s injuries. If the injured person does not own a car nor reside with a relative who owns a car, then the insurer for the vehicle in which the injured person is driving/passenger pays the PIP benefits. When a pedestrian who owns a car (or resides with a relative who owns a car) is struck by a car, then the insurer of the vehicle owned by the pedestrian (or resident relative) pays the PIP benefits. When a pedestrian who does NOT own a car (nor reside with a relative who owns a car) is struck by a car, whether that car is insured or not, then it is a State funded agency (PLIGA) which pays the PIP benefits. When a pedestrian is struck by a non-automobile vehicle(i.e. truck, bus), it is the insurer of the non-automobile vehicle which pays the PIP benefits regardless of whether the pedestrian owns a car.

The standard amount of medical expense benefits is $250,000.00 with a deductible/copay of $1,200 although, for a reduction in premium, a person can choose to have lower limits and higher deductible/copay. This coverage pays for ambulance, hospital, doctors, chiropractors, physical therapists, diagnostic tests(x-rays, mris, catscans, emgs/ncvs), prescription medications, home care attendants for injuries causally related to the mva.

In order to be eligible for reimbursement directly from the PIP insurer, the medical provider needs to have the patient sign an Assignment of Benefits. This must be sent to the PIP insurer, along with the medical provider’s charges setting forth the relevant diagnosis & treatment codes (known respectively as the ICD-9 and CPT codes) and the records documenting/ substantiating the rendered treatment within 21 days of the commencement of treatment(this is known as the "21 day notice"). Payment for the treatment rendered is overdue if not paid within 105 days of when the PIP insurer has all documents/records it needs to make its determination. The amount that the medical provider is entitled to, with limited exception discussed below, is the fee schedule amount set by the State of New Jersey Department of Banking & Insurance (DOBI).

Certain treatment/procedures/diagnostic tests or other services rendered more than 10 days after the accident must be "pre certified" by the PIP insurer. Failure to request pre-certification results in monetary penalties(i.e. reduction in amount paid for said treatment). There are standard "care paths" which must be followed for injuries to certain parts of the body(which are mostly concerned with treatment of neck & back injuries). When the medical provider believes that a certain type/kind of treatment is needed at certain points during the course of treatment (which are known as decision points) the PIP insurer is to undertake a "decision point review" to determine if it agrees with the treating medical provider’s opinion. If the PIP insurer does not so agree, then the medical provider is required to submit an "internal appeal" to the PIP insurer to see if, based upon said submitted info/documentation/records, the PIP insurer will authorize said treatment. If the PIP insurer adheres to its original decision, then the medical provider has the right to challenge said decision by filing a Demand for Arbitration with the National Arbitration Forum. It must be noted that the medical treatment in dispute must actually be rendered and payment for said treatment must be denied by the PIP insurer in order to proceed to arbitration. The typical denials which are arbitrated concern denials based on the PIP insurer’s claim of lack of medical necessity for the treatment at issue and/or that the injuries are not causally connected to the accident. The arbitration process is initiated by filing a Demand for Arbitration with the NAF along with a $225 fee(with an additional $6 for electronically filing through the use of e-law). If the matter does not settle, then a hearing is held before a DRP (Dispute Resolution Professional, i.e. arbitrator) who renders a decision called an Award. If the matter settles or actually results in an Award in favor of the medical provider, the attorney representing the medical provider is reimbursed the above noted filing fee by the PIP insurer as well as being paid his attorney fee by the PIP insurer. Thus, there is no out of pocket expense to the medical provider(the total settlement/award is received by the medical provider). Matters which are eligible for Arbitration concern any treatment which has been rendered within the last 2 years.

When an injured person is taken from the scene of the accident to & treated by a medical provider at a level I or II trauma center (UMDNJ in Newark, Robert Wood Johnson in New Brunswick, Jersey City Medical Center, Hackensack University Medical Center, St, Joe’s in Paterson, Morristown Memorial Hospital, Cooper Hospital in Camden, Capital Health at Fuld in Trenton, Jersey Shore Medical Center in Neptune & AtlantiCare Regional Medical Center in Atlantic City), the medical provider may not be limited to the fee schedule amount for his services, but rather may be entitled to his usual and customary charges as long as they are found to be reasonable. The treatment must be trauma related(i.e required the activation of the trauma unit or required the services/consultation with a trauma care physician).