LOIS Law Firm attorney and Construction Practice Team Partner Tashia Rasul successfully won a judgment of Section 114-a fraud before a New York Workers’ Compensation Law Judge. After covert surveillance captured the Claimant performing activities that contradicted what he represented to his doctors and what he previously testified to under oath, Tashia presented that the Claimant was making material misrepresentations to the Court in order to receive Workers’ Compensation benefits. Continue reading Trial Win: Partner Tashia Rasul Wins Reimbursement for Employer After Claimant Testifies Fraudulently
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WCB Fee Schedule Changes Address Out of State Medical Provider Claims
Effective April1, 2019, the Workers’ Compensation Board changed the Medical fee Schedule in effect for medical payer reimbursement in New York workers’ compensation claims. This will have a significant impact on the many Medical Provider Claims filed by New Jersey doctors and medical providers seeking reimbursement for services rendered to New York workers’ compensation claimants where the Jersey provider is demanding reimbursement at a much higher (“usual and customary”) rate than would be allowed under New York’s fee schedules.
The Changes to the Fee Schedule.
Changes to General Ground Rule 16 govern reimbursement for out-of-state treatment. The Rule now provides that a claimant who lives in New York State may treat with a qualified or Board authorized out-of-state medical provider when such treatment confirms to the Workers’ Compensation law and Regulations, the MTG’s and the Medical Fee Schedule. Payment shall be made to the medical provider as set forth herein and using the regional conversion factor for the zip code where the claimant resides.
How are fee schedule reimbursements determined?
Simple. The methodology for calculating medical reimbursement fees remains unchanged. Fee schedules are both region and activity-specific. To calculate a fee for a particular procedure:
- Identify the appropriate conversion factor, which is listed within the respective Ground Rules document. There is a conversion factor for each geographic region and general type of medical service provided (e.g., surgery, radiology, etc.). For example, in the Medical Ground Rules document, you’ll find the conversion factor table on page 12.
- Once you have the conversion factor you need, find the CPT code for the specific type of service you want to look up.
- For each CPT code, there is a Relative Value Unit (RVU) listed.
- Multiply the RVU by the conversion factor to calculate the fee for that service.
The Takeaway.
The New York Workers’ Compensation Medical fee Schedules now specifically address how providers who render treatment to New York residents out-of-state should be reimbursed. This means that a qualified out-of-state medical provider should be reimbursed (paid) at the rate applicable in the region where the claimant resides (in New York). The Board has continuing jurisdiction to resolve disputes between medical providers and insurers for out-of-state medical care and now has set forth a bright-line rule for how those providers will be reimbursed.
Expedited Trial Strategy: Third Friday Podcast
Host Christian Sison welcomes Greg Lois to his workers’ compensation podcast to discuss expedited trial strategy and preparation in the context of controverted cases before the New York Workers’ Compensation Board.
Continue reading Expedited Trial Strategy: Third Friday Podcast
Trial Win: Noah Pollack On Date of Disablement
In a controverted occupational disease claim where the claimant worked for three separate employers contemporaneously with the alleged disability, and depending on the setting of the date of disablement, either of the three employers could have been found to be the liable party. Adding more difficulty to the defense, our client was actually the last employer for whom the claimant worked. Generally, with occupational disease claims, the last employer is deemed liable, as the date of disablement can be set when the claimant stopped working. Moreover, the first medical reports were filed after the claimant began working for our insured. However, based on testimony taken from multiple employer witnesses as well as the claimant, we successfully argued that because of the claimant’s changed job duties when she began working for our insured (i.e. they were less strenuous), it should be a different employer that should be liable and the date of disablement should be set as the date prior to when the claimant began working for our insured. The Law Judge agreed, and set the date of disablement two days prior to when the claimant began working for our insured, placing liable on a different party. While the claim was established, our client was not deemed liable.
Case: TD v. FSH
Court: Brooklyn Workers’ Compensation Board
Trial Attorney: Noah Pollack, Esq.
Trial-tested LOIS lawyer John Marzolla delivers results
Video: Top Tips for Medical Provider Claims in New Jersey
Attorneys Joe Jones and Gregory Lois present practical methods for closing New Jersey Medical Provider Claims. The attorneys discuss recent case law developments, tactics for negotiating closures, and trial strategy. The video and handout materials (below) are from the live presentation provided to the Firm’s clients on May 6, 2019.
Complete the form below for a copy of the in-depth handout materials:
Continue reading Video: Top Tips for Medical Provider Claims in New Jersey