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Thursday, November 11, 2010

New Jersey Issues Workers Compensation Guidance on Evaluating Disputed Medical Provider Claims

A NJ Workers' Compensation Task Force report has been published that provides guidance to the parties in evaluating disputed medical provider claims. While declaring that, "certainly there are no overnight solutions," the report provides a manual type of suggestions for negotiation, litigation and resolution.

1. The new WCRI report, Benchmarks for Designing Workers’ Compensation Medical Fee Schedules. Fee schedules vary dramatically from state to state and based upon the type of payer;

2. The fees customarily paid for like services within the same community;

3. The fees paid to the same physician or medical provider by other payers for like treatment;

4. The fees billed and the accepted payments for such bills by a given provider. The Court may wish to consider the disparity in payments accepted from different sources (i.e. Medicare vs. PIP and commercial carriers);

5. A review of the Health Insurance Claim Forms (“HCFA”) submitted by the provider to the claim payer and the Explanations of Benefits (“EOB”) that that claim payer sends to the provider. The EOB provides the amount billed for a given procedure or service performed on a particular date of services. The EOB also provides the amount paid and, where applicable, identifies the reason why a disparity may exist in the amount billed and the amount paid. The use of certified professional coders may be employed to review the bill along with the medical records to be sure that it is consistent with CPT coding standards;

6. The HCFAs or EOBs from other medical providers in the same geographic area or community for the same medical treatment provided;

7. Using commercial and/or private databases such as Ingenix’s Prevailing Healthcare Charges System (“PHCS”); the Medical Data Resource (“MDR”) database, and; Wasserman’s Physician Fee Reference (“PFR”) database to name a few;

8. The type of facility where the procedure was performed. For example, was the services provided at a Level 1 trauma center versus a community hospital;

9. Consideration of whether there was a contract between a claim payer and the medical provider, such as a PPO network, in which case the contract would be controlling;

10. Consideration ofMedicare/Medicaid reimbursement rates;

11. Testimony from medical office personnel as to what services were billed for, the payments received and how the bill was formulated;

12. Consideration of state sanctioned PIP fee schedules;

13. Consideration of commercial carrier authorized payments.

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For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.