In a decision issued January 29, 2019 a New Jersey Appellate Court has ruled that even though Medicare includes a CPT code and pays for specific treatment rendered in a ambulatory surgery center this does not obligate a New Jersey auto insurer to make payment for medical treatment billed under such code. At issue were bills submitted to an auto insurance carrier for treatment allegedly rendered in an out-patient facility to the claimant’s low back. The medical fees in dispute involved invoices from the facility not the doctor.
In this case, the facility, Specialty Surgery Center of North Brunswick, sough $32,500 in reimbursement from an automobile insurer for CPT code 63030, which refers to “lower back disc surgery.” The New Jersey Appeals Court ruled that the CPT code provided for reimbursement of physicians only, and not to ambulatory surgery centers. The court further found that despite Medicare’s position on reimbursement for that code, the surgery center was not entitled to payment under New Jersey’s personal injury protection (“PIP”) fee schedule promulgated by the New Jersey Department of Banking and Insurance for automobile claims.
While not mentioning the implications for medical provider claims in New Jersey workers’ compensation cases, this case stands for the proposition that where an ambulatory surgery center is seeking payment for fees that greatly exceed the normal reimbursement and justify those claims by referring to Medicare or other jurisdictional rules, the workers’ compensation carrier can argue that New Jersey’s PIP fee schedule should be relied upon by the workers’ compensation judge as a reasonable estimate of costs (where the surgery center accepts PIP payments). Case discussed: New Jersey Manufacturers Ins. Co. v. Specialty Surgical Center of North Brunswick, A-0319-17T1, A -0388-17T1 (N.J. App. Div. Jan. 29, 2019).
In general, the Federal Employers Liability Act preempts the New York Workers’ Compensation Law unless the parties waive their federal rights and claims. The Board lacks the authority to rule on jurisdictional issues regarding federal claims (such as whether or not the claimant is an employee of the interstate entity. This is because WCL § 113, states that “[t]he provisions of [the New York Workers’ Compensation Law] shall apply to employers and employees engaged in intrastate, and also interstate and foreign commerce for whom a rule of liability or method of compensation may be established by the congress of the United States . . . provided that awards according to the provisions of this chapter may be made by the board . . . in case the claimant, the employer and the insurance carrier waive their admiralty or interstate rights and remedies.”
In a recent case, McCray v. CTS Enterprises, 166 A.D.3d 1356 (3d Dep’t 2018) the court reversed a Board panel decision finding that the Board lacked the jurisdiction to determine issues of employment for employees engaged in interstate railway work because federal law preempted the state workers’ compensation law.
Issue In determining the Schedule Loss of Use (SLU) percentage applicable to a shoulder injury, whether it is appropriate to assign separate loss of use values for deficits in anterior flexion and abduction or if this is duplicative and results in an inflated SLU percentage.
Facts of Case Claimant was a Correctional Officer who injured himself while working in July 2013. The claim was established for a right shoulder injury. At permanency, the claimant’s treating physician opined claimant had 90% SLU of the right arm while an IME opined the claimant had 50% SLU of the right arm. Following litigation of the issue, the law judge credited the IME opinion over that of the treating physician and found claimant to have 50% SLU of the right arm. The Workers’ Compensation Board affirmed the Law Judge’s finding and the claimant appealed to the Third Department.
Decisions of a Workers’ Compensation Judge are appealable directly to the New Jersey Appellate Court. An appeal of the Workers’ Compensation Judge’s opinion must be made within 45 days of the entry of the final order. How does the appeals court rule where there was a disagreement between the doctors who testified in the workers’ compensation case?
The Scope of Review.
The scope of review by the Appellate Division is “the same as that on appeal in any non-jury case, that is, whether the findings made could reasonably have been reached on sufficient credible evidence present in the record, considering the proofs as a whole, with due regard to the opportunity of the one who heard the witnesses to judge of their credibility.” Close v. Kordulak Bros., 44 N.J. 589, 599 (1965), quoting State v. Johnson, 42 N.J. 146, 162 (1964).
Two attorneys cover the fundamentals of appeals from Board decisions. Presenters Declan Gourley and Joseph Melchionne have years of experience representing employers and carriers before the Board. The presentation is designed to help the attendee answer the following questions:
“Should we appeal the Law Judge’s Decision in a workers’ compensation claim?” and
“Does filing the appeal create a stay?” and
“What are the tactical reasons for appealing the Law Judge?”
“What will the appeal cost?”
At the end of the presentation, the attendees will have a basic understanding of the appeals process, tactical aspects of appeals (stays), and the costs of the various types of appeals available.