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.
Continue reading Video: Medicare Secondary Payer Issues in New Jersey Section 20 Settlements
On January 17, 2019 the New Jersey Appellate Division ruled that medical providers filing a “Medical Provider Application for Payment or Reimbursement of Medical Payment” seeking additional money from workers’ compensation insurance carriers have six years to file their claims. This is longer than the two year Statute of Limitations which applies to the underlying workers’ compensation claim. This decision will increase the number of Medical Provider Claims filed in New Jersey.
Reasoning of the Appellate Court.
In The Plastic Surgery Center, PA. v. Malouf Chevrolet-Cadillac, Inc, the New Jersey Appellate Division decided that a medical provider has to file a claim in the Division of Workers’ Compensation within six years of the service provided. The case has been reported.
The Court noted that suits on contracts in New Jersey have a six-year statute of limitations under N.J.S.A. 2A:14-1. When the New Jersey Legislature amended the New Jersey statute in 2012 granting exclusive jurisdiction over disputed medical charges to the Division of Workers’ Compensation, the Legislature never addressed which statute of limitations would apply. The Court found that the rationale for a two year statute of limitations does not fit N.J.S.A. 34:15-51, which is the statute of limitations provision in New Jersey. The Court ruled that
“[w]e are most persuaded that the Legislature intended to leave unaltered the time within which medical-provider claims must be commenced because the Act’s two-year-bar simply doesn’t fit.”
The Court found that a two-year rule could mean that the statute would run on the rights of the medical provider to file before the medical service is even provided because the medical provider might not render its service until after two years from the date of accident.
Impact of this Decision.
According to the statistics provided by the Division of Workers’ Compensation, one of every five claim petitions in New Jersey is a Medical Provider Claim. This decision will likely embolden medical providers, working outside of New Jersey but closely watching the medical provider claim action in this State because they are covetous of the “usual and customary” (extremely high) payment scheme, to accelerate the trend of opening satellite offices in New Jersey and with he plan of continuing to persuade their patients to “cross a river” and seek ambulatory surgery, procedures, and treatment in New Jersey at a much higher cost to the carrier.
This decision does not address the payment to be reimbursed where the claimant’s only contact with the state of New Jersey is the place of treatment rendered. Right now there are conflicting decision issued by trial-level judges (Judge of Compensation) in the many workers’ compensation courts (vicinages).
LOIS successfully defended an employer directly against a workers’ compensation claim and got them dismissed from the claim. The employer hired us directly to defend their interests in a workers’ compensation claim filed against them. An employee leasing entity provided the employee along with worker’s compensation coverage. The employer leasing company argued that they had terminated their contract of services with the employer and were therefore not responsible. We successfully argued that the statute for termination of insurance coverage was applicable and that they had not complied. First, the employer leasing company only provided a copy of the termination letter, but had not shown any proof of mailing or proof of service. Second, the accident occurred 2 days later (on a Sunday). The Judge entered an order against the employer leasing company and dismissed our client from the claim.
Case: RP v. IG;
Lois Attorney: Karen Vincent, Esq.
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.
Continue reading Video: Reimbursement and Subrogation in New Jersey