Category Archives: New Jersey

Proofs Required to Oppose Motion for Benefits In New Jersey

The New Jersey Appellate Division recently rendered a decision on October 10, 2019 dealing with the quality of proofs required when filing a Med/Temp Motion or the opposition to same.  While the decision is “unpublished” and therefore not binding precedent upon any court,  the takeaways from the Appellate Division’s decision are useful for claims professionals and attorneys when obtaining proofs, considering proofs and ultimately submitting proofs to the court in opposition to Motion for Medical and Temporary Disability benefits.

NJ Workers’ Compensation rules provide that affidavits, certifications or medical reports may be submitted in support of, or in opposition to, a Motion for Medical and Temporary Benefits but those proofs must meet certain standards to be considered by the Court.

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TRIAL WIN: Attorney Karen Vincent Prevails on Dismissal in New Jersey

LOIS attorney Karen Vincent prevailed in the defense of a motion to restore in the New Jersey Workers’ Compensation Court. In that case, where Vincent represented the carrier, the petitioner filed a formal claim petition alleging an accident on June 11, 2016 with significant injuries to the lumbar spine. LOIS filed a Motion to Dismiss for lack of employment arguing that the petitioner was a 1099 independent contractor. Petitioner was unable to oppose the original Motion and instead requested a consensual dismissal without prejudice for lack of prosecution.

Several months later, the petitioner filed a Motion to Restore the claim. LOIS again prepared Opposition to the Motion advising that the petitioner had not provided any new discovery to prove employment.

On July 16, 2019, this case was listed as the Motion to Restore. Petitioner’s attorney requested the Court consider allowing him to withdraw the Motion without prejudice so that he could further investigate employment. However, Attorney Vincent pointed out to the Judge that the case had originally been dismissed for that same reason and that the accident was now three years old.

In light of same, the Judge of Compensation held a hearing on the Motion and attorney Karen Vincent won a dismissal WITH prejudice, which is beneficial to the employer because it means the petitioner can never bring those claims again.

Appeal Win: Greg Lois Prevails in New Jersey Appellate Decision

On July 9, 2019 and in a decision favorable to the employer, the New Jersey Appellate Division vacated an order awarding money benefits to the petitioner and returned the case to the trial court. This remand for new trial, obtained after oral argument presented by Greg Lois, also vacated an order penalizing the employer for late payment of lost time benefits.

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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.