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).
Attorney Greg Lois Attorney Gregory Lois leads a discussion on the challenges facing parties seeking to resolve disputes via New Jersey’s Section 20 lump-sum dismissal process where Medicare has an interest. This video is taken from the January 28, 2019 webinar provided by the Firm.
Effective January 1, 2019, the maximum temporary disability compensation benefit rate for New Jersey claims rises to $921.00 per week and the minimum rate is $246 per week. These rates take effect for new injuries occurring on or after January 1, 2019. Benefit rates in cases with dates of loss prior to January 1, 2019 do not get this higher rate – New Jersey does not have a cost of living increase for established claims. Continue reading New Jersey’s Maximum Benefit Rate Increase in Effect Now for New Claims→
Attorneys Joe Jones and Greg Lois discuss the recovery of benefits issued by the workers’ compensation carrier from the proceeds of civil actions in New Jersey. This video is taken from the December 24, 2018 webinar provided by the Firm.
This is the PDF (Adobe Acrobat) version of “New Jersey Workers’ Compensation Law – 2019 Edition” by Gregory Lois. This is the most practical, up-to-date and easy-to-understand guide to New Jersey workers’ compensation claims available. This book is designed for employers, attorneys, claims adjusters, physicians, self-insured employers and vocational rehabilitation workers. This guide is written in plain English by a New Jersey attorney and provides a detailed analysis of relevant statutes and regulations; a complete recap of recent court decisions; and a full description of current practice and procedure. This book provides a behind-the-scenes look at the complicated issues and makes the law understandable for business owners.
A comprehensive description, including a list of what was updated since the last edition and complete chapter list is here.