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(c) 2014 Jon L Gelman, All Rights Reserved.

Thursday, October 28, 2010

NJ Rejects Broad Medicare Release Language in Judgments

The NJ Division of Workers Compensation has indicated that broad release "language should not be included as part of a settlement order, attached to a settlement order or placed or part of the settlement record."

Specifically the following sample language was rejected, The claimant, , agrees to indemnify defendant, hold harmless the respondent from any action by Medicare seeking payment of past, current or future medical expenses for the claimant. Claimant shall further hold the respondent harmless from any and all adverse consequences in the event the settlement results in the loss of right to Social Security and/ Medicare benefits to the extent claimant would have been entitled to those benefits in the absence of the settlement agreement."

A memo was issued on October 28, 2010, by the Director and Chief Judge, The Honorable Peter J. Calderone.
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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.

Workers Compensation and Nanotechnology - The New Frontier

NIOSH research has revealed that breathing nanoparticles may result in damaging health effects.

"Nanotechnology has the potential to revolutionize countless products, create computers smaller and faster than once could be imagined, and fight diseases such as cancer. According to the Project on Emerging Nanotechnology, by the summer of 2009 there were 1,015 consumer products using nanotechnology. That represents nearly a 19-fold increase over the 54 products listed in 2005. Nanotechnology involves the manipulation of matter at a near-atomic scale. Nanoparticles measure from 1 to 100 nanometers in size, with 1 billion nanometers forming a meter. For comparison, a billion inches would nearly circle the Earth 2 times."
  • A 2004 survey estimatedthat nearly 25,000 U.S. workers were employed at businesses that exclusively produced nanotechnology products.
  • Nanoparticles can enter the body through many routes including inhalation, swallowing, ingestion, and absorption through the skin.
  • Nanotechnology may present health risks but it can also be used to protect workers. New respirator designs, for instance, use nanotechnology to create more effective filters to block harmful substances.
Authors of Inhalation Versus Aspiration of Single-Walled Carbon Nanotubes in C57BL/6 Mice: Inflammation, Fibrosis, Oxidative Stress, and Mutagenesis—Anna Shvedova, Elena Kisin, Ashley Murray, Victor Johnson, Olga Gorelik, Sivaram Arepalli, Ann Hubbs, Robert Mercer, Phouthone Keohavong, Nancy Sussman, J. Jin, J. Yin, Samuel Stone, The-hsun Chen, Gregory Deye, Andrew Maynard, Vince Castranova, Paul Baron, and Valerian Kagan; Health Effects Laboratory Division; NIOSH—received the 2009 Alice Hamilton Award in the Biological Sciences category.
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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.

Monday, October 25, 2010

A New Wave of Disease - Cleaners Asthma

Workers exposed to chlorine agents have been diagnosed with respiratory impairments. A recent study has reported that "suggest that bleach inhalation at a concentration of 0.4 ppm—a concentration below 8-hr permissible occupational exposure level—brings about a substantial decrease in FEV1 in subjects."

"Included in the study were thirteen cleaning employees with work-related asthma-like symptoms, three asthmatic controls and three atopic subjects without bronchial hyperresponsiveness (BHR) who had no exposure to cleaning products. The study protocol consisted of a methacholine test, sputum induction and fraction of exhaled nitric oxide measurement (FENO) both at baseline and 24 hr after a 1-hr inhalation challenge with either placebo or bleach at a concentration of 0.4 ppm of chlorine."

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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.


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Saturday, October 23, 2010

Senator Dorgan Call for Medical Evaluations for Those Exposed to Sodium Dichromate at Qarmat Ali Iraq

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Senator Byron L. Dorgan has called for medical evaluation and monitoring of personnel who were exposure to toxic agents in Iraq including Sodium Dichromate. The Inspector General released the first of two reports calling for notification of those potentially exposed to the toxic substances.

"The Commander, U.S. Army Corps of Engineers should notify all current and former military personnel who were identified as having served at the Qarmat Ali facility in 2003 of their eligibility for the Department of Veterans Affairs Gulf War Registry and associated sodium dichromate exposure-related medical evaluation.


The Under Secretary of Defense for Personnel and Readiness should:

  • • publicize the eligibility of active duty personnel who served at the Qarmat Ali facility in 2003 for the Department of Veterans Affairs Gulf War Registry
  • • review policy and procedures for active duty personnel eligible to undergo the Department of Veterans Affairs Gulf War Registry medical evaluation
  • • develop and publicize a means to offer DoD civilians who served at Qarmat Ali in 2003 an exam and medical surveillance similar to what the Department of Veterans Affairs avails to military personnel and veterans.

"I am very concerned about the findings we now have, and I am disappointed in the delayed release of Part II of this report. The IG's investigation and its findings are very important to the lives of U.S. soldiers and workers who were at the site. Details and definitive findings will help us ensure accountability for this exposure and flawed follow up, but even more importantly, they will help ensure that all exposed soldiers receive appropriate notice and medical attention," Dorgan said.


Former soldiers and civilian employees have brought claims against military contractors for alleged negligence in deviating from purported military contract responsibilities that have been illegally caused illness and fatal disease to those exposed. 

Working Overtime Results in Compensation Heart Attack

Working overtime that resulted in a heart attack was deemed to be a compensable dependency claim.

"The compensation judge held that Anthony's overtime work contributed in a material way to his heart attack. In reaching that conclusion, the judge found that the work effort was more intense than the normal wear and tear of Anthony's daily living."

"The parties agree that the overtime work was more strenuous for Anthony than daily living tasks. Glen Gery required Anthony to change heavy paddles or blades that churned the water and shale. To access the blades, he was required to use a jackhammer to remove hardened material, each chunk weighing between thirty and forty pounds. Once the hardened material was removed, certain blades had to be replaced. To replace the blades, a shaft weighing approximately 200 pounds had to be lifted off the ground by at least two workers who were required to push, lift and pull until each new blade was secured. Anthony worked that day performing intense manual labor in a hot and dusty environment."

"Dr. Malcolm Hermele, petitioner's expert, opined that the heart attack occurred on the day Anthony worked overtime, and that his work effort contributed materially to it. Hermele pointed to the results of tests performed the day after Anthony worked overtime to prove when the heart attack occurred. A creatine kinase (CK) enzyme test showed a reading of 1453. A normal reading would be zero. He explained that the CK enzyme is released into the blood stream when there is damage to the heart. Anthony's troponim levels and the result of his brain natriuretic peptide test show that he was experiencing a heart attack. Hermele concluded that a 1453 reading was evidence that Anthony's heart attack occurred within a day or two of the test, during which Anthony performed the overtime maintenance work."

Reading v. Glen Gery Shale and Brick Company, Not Reported in A.3d, 2010 WL 4137298 (N.J.Super.A.D.)Decided October 21, 2010

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

No Social Security COLA for 2011


Like so many state workers' compensation programs, Social Security and Supplemental Security Income (SSI) benefits for more than 58 million Americans will not automatically increase in 2011, the Social Security Administration announced.


The Social Security Act provides for an automatic increase in Social Security and SSI benefits if there is an increase in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W) from the third quarter of the last year a cost-of-living adjustment (COLA) was determined to the third quarter of the current year.  As determined by the Bureau of Labor Statistics, there is no increase in the CPI-W from the third quarter of 2008, the last year a COLA was determined, to the third quarter of 2010, therefore, under existing law, there can be no COLA in 2011.

Other changes that would normally take effect based on changes in the national average wage index also will not take effect in January 2011.  Since there is no COLA, the statute also prohibits a change in the maximum amount of earnings subject to the Social Security tax as well as the retirement earnings test exempt amounts.  These amounts will remain unchanged in 2011.  The released agency fact sheet provides more information on 2011 Social Security and SSI changes.

Information about Medicare changes for 2011, when available, will be found at www.Medicare.gov.  The Department of Health and Human Services has not yet announced if there will be any Medicare premium changes for 2011.  Should there be an increase in the Medicare Part B premium, the law contains a “hold harmless” provision that protects more than 70 percent of Social Security beneficiaries from paying a higher Part B premium, in order to avoid reducing their net Social Security benefit.  Those not protected include higher income beneficiaries subject to an income-adjusted Part B premium and beneficiaries newly entitled to Part B in 2011.  In addition, almost 20 percent of beneficiaries have their Medicare Part B premiums paid by state medical assistance programs and thus will see no change in their Social Security benefit.  The state will be required to pay any Medicare Part B premium increase.

For additional information about the 2011 COLA, go to www.socialsecurity.gov/cola.

For additional information about changes in the national average wage index, go to www.socialsecurity.gov/OACT/COLA/AWI.html.
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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 who have sought Social Security Disability Insurance (SSDI) Benefits.

Thursday, October 21, 2010

Labor Secretary Solis reports a decline in workplace injuries and illnesses






The U.S. Department of Labor's Bureau of Labor Statistics today announced that nonfatal workplace injuries and illnesses among private industry employers declined in 2009 to a rate of 3.6 cases per 100 equivalent full-time workers, down from a total case rate of 3.9 in 2008. BLS also reported a decline in the total number of cases from 3.7 million in 2008 to 3.3 million in 2009. Secretary of Labor Hilda L. Solis issued the following statement:
"While the reported decline in workplace injuries and illnesses is encouraging, 3.3 million workplace injuries and illnesses are 3.3 million too many. No worker should fear being injured or made sick for a paycheck.
"Complete and accurate workplace injury records can serve as the basis for employer programs to investigate injuries and prevent future occurrences. Most employers understand this and do their best to prevent worker injuries, but some do not. That is why my department's Occupational Safety and Health Administration is aggressively working to ensure the completeness and accuracy of injury data compiled by the nation's employers. We are concerned about the widespread existence of programs that discourage workers from reporting injuries, and we will continue to issue citations and penalties to employers that intentionally under-report workplace injuries.
"Too many Americans suffer each year from preventable injuries or illnesses they received while on the job. Even in these difficult economic times, we must keep in mind that no job is a good job unless it's a safe job."
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For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.

Patent Awarded for Compensatory Patient Invoicing

The US Patent Office has issued a patent to Stephen Ambrose for a system and method for enabling health care providers to effect compensatory invoicing of patients who use a coverage entity in addition to their health insurer.

Stephen Ambrose is the President of ICEX Data Reporting a Virginia area information technology and services company.

A system and method is provided for compensatory invoicing of a patient for health care services rendered by a Health Care Provider. The system and method enables a Health Care Provider to obtain payment of Full Rates for services rendered to a patient in circumstances where a Health Insurance Entity provides less than full-rate compensation (e.g., compensation at Contracted Rates) to the Health Care Provider AND the patient has been reimbursed additionally by another payment party for claims already paid for by the Health Insurance Entity. In one implementation, the patient contracts with the Health Care Provider to ensure that the Health Care Provider is fully compensated for the services rendered after the patient receives payments from a tortfeasor and/or First and/or Third Party Payment Entity (e.g., an auto insurance carrier, worker's compensation insurance carrier, Medpay, PIP etc.) for the services. The invention tracks claim(s) filed by the patient against the tortfeasor and/or First and/or Third Party Payment Entity and tracks payments) made by the tortfeasor and/or First and/or Third Party Payment Entity to the patient. The patient and/or the First and/or Third Party Payment Entity is then billed for the difference in payments made to the Health Care Provider by the Health Insurance Entity, effecting compensatory invoicing for a Full Rate fee chargeable by the Health Care Provider in cases when a tortfeasor and/or First and/or Third Payment party has reimbursed the patient for similar services as already reimbursed by the Health Insurance Entity.

BACKGROUND OF THE INVENTION

In the current health care arena, physicians, hospitals, and other health care providers (hereinafter the "Health Care Provider") contract with health insurance companies, managed care organizations ("MCOs"), or other health insurance providers (hereinafter the "Health Insurance Entity"). Typically, both a Health Care Provider and a patient have a contractual relationship with a Health Insurance Entity. In general, when a patient visits an "in-network" Health Care Provider, the patient receives services which are subsequently billed to the Health Insurance Entity by the Health Care Provider. The Health Insurance Entity is typically the primary payer for services and will cover necessary treatment and care for the patient's various health problems, including acute injuries.

Upon contracting with the Health insurance Entity, the Health Care Provider generally agrees to accept contracted rates set by the Health Insurance Entity (hereinafter "Contracted Rates"). These Contracted Rates are typically lower than the normal, full-rate fees charged by the Health Care Provider (hereinafter "Full Rates") for the delivery of a variety of billable services. In return, the Health Care Provider is given access to the Health Insurance Entity's patients, some of whom may be assigned to the Health Care Provider. The Health Care Provider also agrees that, during the term of the patient's coverage by the Health insurance Entity, if the patient is to be billed for the Health Care Provider's services directly for any reason, the Health Care Provider can only bill at the Contracted Rates for the services performed, provided that these are services normally paid for by the Health Insurance Entity.

In most Health Insurance Entity/Health Care Provider contracts, the Health Care Provider is prohibited from billing a patient for any amounts attributable to the difference between the Health Care Provider's Full Rates and the Contracted Rates. This type of billing, is known commonly as "Balance Billing" i.e., billing the patient for the balance between the Contracted Rates and the Full Rates). The difference in rates can sometimes he quite large. Thus, while a Health Care Provider obtains some benefits from contracts with Health insurance Entities, certain financial drawbacks exist.

When a patient visits a Health Care Provider for medical attention of injuries, symptoms, or disease stemming from an accident or other event for which there is an applicable liability insurance product and/or an individual, group or business who is determined responsible in a court of law or otherwise, for the patient's injury or reason for obtaining medical attention (hereinafter known as "tortfeasor"), there may be instances when one or more parties other than a Health Insurance Entity, such as a first and/or third party payer as well as compensation paid by a tortfeasor to the patient and/or their Agent may provide payments for the Health Care Provider's services. For example, in the case of an auto accident, the first party payer may be the auto insurance company for any injured individual through an attached medical payment rider, regardless of fault in the accident (hereinafter "Medpay") or the insurer for any auto insurance rider known as
Personal Injury Protection (hereinafter "PIP"). Medpay, PIP insurers and other first party payment entities can be referred to as a first party payer (hereinafter "First Party Payment Entity"). Another example is the patient or their use of an attorney, agent or legal representative (hereinafter "Agent") in utilizing their health care bills in part or full, so as to obtain a legal judgment and/or agreement with the tortfeasor, allowing for payment to the patient and/or their Agent. An example of a third party payer may be the automobile (or other) liability insurance company for the driver (or other entity) who was "at-fault" or responsible for the Covered Event, e.g. for causing the auto (or other) accident and the injuries for which the injured, non-responsible party received treatment. Third party payers, for example, may include auto insurance carriers, liability, property & casualty and worker's compensation insurance carriers, and other third party payers, among other types of entities (hereinafter "Third Party Payment Entity"). For example, if a patient visits a Health Care Provider because he or she was in an automobile accident, the patient's Health Insurance Entity may be billed, and the patient's Health Insurance Entity may subsequently pay medical bills to the Health Care Provider who provided services to the patient. In some instances, the Health Insurance Entity may elect to seek reimbursement for monies paid for services from a First and/or Third Party Payment Entity who has also paid monies for similar health services, through a process known as subrogation.

However, in many jurisdictions (e.g., states), there is a legal doctrine known as the "
Collateral Source Rule" that, allows an injured, patient and/or their Agent to submit medical bills to a First and/or Third Party Payment Entity, even if the bills have already been paid by the Health Insurance Entity to the respective health care provider(s). The Collateral Source Rule prohibits the admission at trial of evidence that a patient's injuries were already compensated from a health insurance policy or other source of compensation. For example, in a personal injury case, evidence that a Plaintiffs medical bills were paid by his or her medical insurance are not admissible. This is largely because the Collateral Source Rule is intended to promote justice and assess remedies for fault of the tortfeasor (the entity or entities that caused the injury).

Additionally, some insurance or other payment sources that pay for an injured party's damages may gain a lien or right of subrogation in any ultimate recovery by or on behalf of the injured party. In these circumstances, the injured patient must pay back the party with the subrogation right, who had previously paid on charges from Health Care Providers), assuming the patient received additional payment for the same billed services by other payment sources other than the party with the subrogation rights.

One problem with this system is that complete and full rate payment may not be made to the Health Care Providers for services performed and billed. Agents and/or injured parties however, can submit the Health Care Provider's medical bills as part of a lawsuit and/or directly to a tortfeasor and/or to a First and/or Third Party Payment Entity and receive compensation at Full Rates, even if the medical bills were already paid. Thus, the Health Care Provider receives payment at the lower Contracted Rates, while the patient and/or their Agent through utilizing the provider's bills, can receive compensation paid by a tortfeasor to the patient and/or their Agent as well as by a First and/or Third Party Payment Entity at the higher Health Care Provider's Full Rates.

Additionally, many Health Care Provider/Health Insurance Entity contracts provide for a waiver of subrogation on the Health Care Provider's part. Subrogation is a legal concept where one entity assumes the legal rights of another entity for whom the first entity has paid expenses or a debt on their behalf. For example, when an insurer is required to pay a claimant a sum of money, the insurer usually is allowed to sue in the name of the claimant against any person who was responsible for the loss. This concept enables an insurance company to sue on behalf of its insured if it is required to pay the insured for a loss caused by another entity. Subrogation is generally considered in most legal systems to form part of the law of restitution by preventing unjust enrichment. In other words, subrogation prevents the subrogor (e.g., the patient) from receiving/utilizing funds from the subrogee (e.g., the health care insurer), and then still claiming the original sum of money from the tortfeasor (e.g., the entity that caused the accident). Pursuant to the waiver of subrogation, the Health Insurance Entity may be able to recover any payments made for services provided to a patient following an auto accident or other Covered Event, provided that the First and/or Third Party Payment Entity paid monies for the same set of services. Thus, even if the Health Insurance Entity receives payment at the Full Rates, the Health Care Provider gets nothing more than the Contracted Rates. In this sense, patients, attorneys and other parties can leverage the Health Care Provider's efforts to financially benefit. for themselves, many times at the full fee rates, while the Health Care Provider receives only the Contracted Rates.

These and other drawbacks exist with known billing practices. 

What is claimed is:

1. A billing and payment collection method utilized by a health care provider to bill and collect payment associated with treatment of a patient, the method comprising: transmitting a health care service bill from the health provider to a patient's health insurance plan for health care services provided to the patient by the health care provider, wherein the health care service bill is for the normal and full charge for the rendered health care services; accepting a contractual rate payment from the health insurance plan in response to the transmitted health care service bill, wherein the contractual rate payment is lower than the health care provider's normal and full charge for the rendered health care services; determining that an additional payment party exists, which is not the patient's health insurance plan, wherein the additional payment party is responsible to pay the patient for the health care service bill, when submitted by the patient, irrespective of the patient's health insurance plan paying the health care provider for the same health care service bill; entering into a private billing contract between the health care provider and the patient for differential monies, wherein the differential monies are the difference between the normal and full charge for the rendered health care services, and the contractual rate payment made by the health insurance plan in response to the health care service bill, wherein the differential monies are only due to the health provider upon the patient submitting the health care service bill to an additional party and receiving payment therefrom; submitting via the patient the health care service bill to the additional payment party; receiving, by the patient, from the additional payment party monies in response to the submitted health care service bill, wherein the received monies includes differential monies; billing and collecting the differential monies from the patient by the health care provider based upon the private billing contract; and wherein the prior steps are performed by one or more computers.

2. The method of claim 1, wherein the billing and collection for the health provider is performed by a third party.

3. The method of claim 1, wherein the patient submits the health care service bill to the additional payment party via an attorney or legal representative.

4. The method of claim 1, wherein the health care service bill relates to an injury claim involving the patient.

5. The method of claim 1, wherein the private billing contract is made prior to any care being rendered by the health care provider to the patient.

6. The method of claim 1, wherein the health care provider is a provider selected from a group consisting of a health system, hospital, surgical center, rehab facility, physician's practice, ambulatory center, medical service business, imaging center, outsourced diagnostic testing company, home health agency, therapy clinic, chiropractic and any non-medical practitioner and facility legally allowed to perform health care services.

7. The method of claim 1, wherein the health care services are services selected from a group consisting of consultation, examination, treatment, surgery, use of pharmaceutical products, home health, therapy, imaging, laboratory services and use of medical equipment.

8. The method of claim 1, wherein the additional payment party is based upon an insurance rider selected from a group consisting of a Med Pay, No-Fault, Uninsured Motorist, Underinsured Motorist and Personal Injury Protection riders on an automobile insurance of the patient.

9. The method of claim 1, wherein the additional payment party is based on a liability insurance product representing the at-fault party, selected from a group consisting of general liability, professional liability, auto liability, employer liability, public liability and product liability.

10. The method of claim 1, wherein the additional payment party is a party selected from a group consisting of an individual, group, business, partnership, limited liability company, insurance coverage, association, municipality, county, state, and federal government entity.

11. The method of claim 4, wherein the injury claim is based upon an injury selected from a group consisting of an auto accident, work-related injury, soft-tissue injury, liability on premises, liability due to environment, product defect, pharmaceutical product, birth injury, assault, slip, fall, circumstance relating negligence and medical malpractice.

12. The method of claim 1, wherein the private billing contract is a medical lien between the provider and patient.

13. The method of claim 1, wherein the submission of the health care service bill to the additional payment party by the patient is conducted via an attorney or legal representative.

14. The method of claim 1, wherein the differential monies exclude monies paid to the health care provider, said excluded monies selected from a group consisting of a health insurance co-payment, a health insurance deductible and co-insurance.

15. The method of claim 4, wherein the health care provider collects differential monies relating to the injury claim from the patient via an attorney or legal representative of the patient.

16. A computerized investigation method to determine whether differential monies legally owed to a health care provider by a patient are in the possession of the patient, the method comprising: transmitting a heath care service bill from the health provider to the patient's health insurance plan for health care services provided to the patient by the health care provider, wherein the health care service bill is for the normal and full charge for the rendered health care services accepting a contractual rate payment from the health insurance plan in response to the transmitted health care service bill, wherein the contractual rate payment is lower than the health care provider's normal and full charge for the rendered health care services; determining an additional payment party exists, which is not the patient's health insurance plan, wherein the additional payment party is responsible to pay the patient for the health care service bill, when submitted by the patient, irrespective of the patient's health insurance plan paying the health care provider for the same health care service bill; entering into a private billing contract between the health care provider and the patient, wherein existing differential monies are deemed owed from the patient to the health care provider, wherein the differential monies are the difference between the normal and full charge for the rendered health care services, and the contractual rate payment made by the health insurance plan in response to the health care service bill, wherein the differential monies are only due to the health provider upon the patient submitting the health care service bill to an additional party and receiving payment therefrom; submitting via the patient the health care service bill for the rendered health care services to the additional payment party; determining by the health care provider, through an investigation, that the patient received monies from the additional payment party in response to the submitted health care service bill, wherein the received monies include the differential monies; and wherein the prior steps are performed by one or more computers.

17. The method of claim 16, wherein the additional payment party is based upon an insurance rider selected from a group consisting of a Med Pay, No-Fault, Uninsured Motorist, Underinsured Motorist and Personal Injury Protection riders on an automobile insurance of the patient.

18. The method of claim 16, wherein the additional payment party is based on a liability insurance product representing the at-fault party, selected from a group consisting of general liability, professional liability, auto liability, employer liability, public liability and product liability.

19. The method of claim 16, wherein the additional payment party is a party selected from a group consisting of an individual, group, business, partnership, limited liability company, insurance coverage, association, municipality, county, state, and federal government entity.

20. The method of claim 16, wherein the injury claim is based upon an injury selected from a group consisting of an auto accident, work-related injury, soft-tissue injury, liability on premises, liability due to environment, product defect, pharmaceutical product, birth injury, assault, slip, fall, circumstance relating negligence and medical malpractice.

21. The method of claim 16, wherein the private billing contract is a medical lien between the provider and patient.

22. The method of claim 16, wherein the submission of the health care service bill to the additional payment party by the patient is conducted via an attorney or legal representative.

23. The method of claim 16, wherein the investigation for the health care provider is performed by a third party.

24. The method of claim 16, wherein the patient submits the health care service bill to the additional payment party via an attorney or legal representative.

25. The method of claim 16, wherein the health care service bill relates to an injury claim involving the patient.

26. The method of claim 16, wherein the private billing contract is made prior to any care being rendered by the health care provider to the patient.

27. The method of claim 16, wherein the health care provider is a provider selected from a group consisting of a health system, hospital, surgical center, rehab facility, physician's practice, ambulatory center, medical service business, imaging center, outsourced diagnostic testing company, home health agency, therapy clinic, chiropractic and any non-medical practitioner and facility legally allowed to perform health care services.

28. The method of claim 16, wherein the health care service is a service selected from a group consisting of consultation, examination, treatment, surgery, use of pharmaceutical products, home health, therapy, imaging, laboratory services and use of medical equipment.

29. The method of claim 16, wherein the differential monies exclude monies paid to the health care provider, said excluded monies selected from a group consisting of a health insurance co-payment, a health insurance deductible and co-insurance.

SUMMARY OF THE INVENTION

The invention addressing these and other drawbacks relates to a system and method for enabling a Health Care Provider to effect compensatory invoicing of patients for a Covered Event in instances where the patient has contracted with a Health Insurance Entity for provision of health care services at a Contracted Rate and additionally, there exists compensation paid by a tortfeasor to the patient and/or their Agent and/or a responsible First and/or Third Party Payment Entity who is liable for payment due to the Covered Event.

According to an aspect of the invention, a Health Care Provider may take one or more steps to ensure that it is in a legal position to effect compensatory invoicing of a patient to effectively bill a patient, while honoring the Health Care Provider/Health Insurance Entity Contract (under certain circumstances) by enforcing a billing arrangement which would enable the Health Care Provider to be paid their Full Rate when a patient or their Agent receives compensation paid by a tortfeasor and/or First and/or Third Party Payment Entity other than their Health Insurance Entity.

For example, in one implementation, a Health Care Provider, prior to rendering services to a new (or current) patient who is seeking care stemming from a Covered Event, requires the patient to sign a legal contract between the patient and the Health Care Provider, specifically outlining the billing policies of the Health Care Provider, where the contract includes a provision entitling the Health Care Provider to be entitled to their Full Rate (not the Contracted Rate) if the patient and/or their Agent uses the Health Care Provider's bills for compensation by submitting the bills to a tortfeasor via a lawsuit or otherwise and/or First and/or Third Party Payment Entity (e.g., an entity other than the Patient's Health Insurance Entity).

Once a signed contract is in place by and between the patient and the Health Care Provider, the Health Care Provider provides necessary services to the patient in the ordinary course, bills the Health Insurance Entity at the Contracted Rates, and receives payment from the Health Insurance Entity for the rendered services at the Contracted Rates.

Subsequently, the Health Care Provider (or someone on behalf of the Health Care Provider) may monitor a variety of sources to determine whether the patient and or their Agent has had compensation paid by a tortfeasor and/or a First and/or Third Party Payment Entity relating to services provided by the Health Care Provider. Monitored sources may, for example, include Court records (electronic or otherwise) as well as the use of various health provider and billing databases, many of which are currently known (but used for other purposes). This may also include providing a questionnaire with the paperwork which the patient fills out and signs at the Health Care Provider's office prior to, during or subsequent to treatment, asking if the injury or reason the patient is seeking care stems directly from an accident or Covered Event, and if so, identification of any pending lawsuits or submission of provider's health bills to a tortfeasor and/or First and/or Third Party Payment Entities. The requesting of treatment records, bills, statements, etc. either by the patient or a representative (agent) of the patient may also be a trigger, alerting the Health Care Provider and related staff that compensatory invoicing may be appropriate.

Monitoring may further be performed manually and/or electronically at predetermined intervals or otherwise. Additionally, the patient may also allow the Health Care Provider to bill the First and/or Third Party Payment Entity as well as collect from the patient and/or their Agent any compensation paid by a tortfeasor to the patient and/or their Agent. Whichever the case, the Health Care Provider (or agent) enforces the billing contract between the Health Care Provider and the patient to effect compensatory invoicing and collect the difference between the Full Rates and the Contracted Rates in appropriate circumstances.

According to an aspect of the invention, a system is provided, which enables the review and subsequent auditing of past patient records by comparing them against a monitoring system allowing the Health Care Provider to effect compensatory invoicing and collect any difference(s) between their Full Rate(s) and Contracted Rate(s) for rendered services if the patient and/or their agent/representative uses the Health Care Provider's bills and has compensation paid by a tortfeasor and/or First and/or Third Party Payment Entity (e.g., an entity other than the Patient's Health insurance Entity).

In one implementation, the system may comprise a computer system, and the computer system may further host, interface with, or otherwise enable access to a billing management application for tracking information/contracts for those patients who are seeking payment for healthcare services (either in full or in part) from a tortfeasor and/or a First and/or Third Party Payment Entity (other than the Patient's Health Insurance Entity). The billing management application may comprise an "add-on" application to existing or subsequently developed billing applications, or may comprise a separate "stand-alone" application.

In one implementation, the computer system (and billing application) may be in operative communication with one or more external data sources (e.g., legal databases that include information on Court proceedings and other data sources). Information gathered from the one or more external data sources may be maintained, for example, in one or more associated databases. The information may comprise, among other things, information on claims filed by patients (contracting with the Health Care Provider) and/or their Agent against any tortfeasor and/or First and/or Third Party Payment Entity (other than the patient's Health Insurance Entity) and the status of any such proceedings related to the claims. The information may also comprise data on any payment-related activities that have occurred between contracted patients and any tortfeasor and/or First and/or Third Party Payment Entity.

For each patient contracting with the Health Care Provider, die billing management application may generate reports on-demand, or at pre-determined intervals, that include the current status of any efforts by the particular contracting patient to recover money from a patient and/or Agent in lieu of a tortfeasor's compensation as well as a First and/or Third Party Payment. Entity (other than the patient's Health insurance Entity).

In one implementation, if a patient has been compensated by a tortfeasor and/or First and/or Third Party Payment Entity, the billing management application may generate, pursuant to the contract between the patient and the Health Care Provider, a bill for the difference between the Health Care Provider's Full Rates (for services rendered by the Health Care Provider to the patient) and the payment received by the Health Care Provider from the Health Insurance Entity at the Contracted Rates.

Various other objects, features, and advantages of the invention will be apparent through the detailed description of the preferred embodiments and the drawings attached hereto. It is also to be understood that both the foregoing general description and the following detailed description are exemplary and not restrictive of the scope of the invention. 

Opportunities, Challenges in Use of Workers’ Comp Data Are Examined in NIOSH Workshop Proceedings Report

Opportunities for maximizing the use of workers’ compensation data for occupational safety and health surveillance and research - and challenges that researchers face in exploring those opportunities - are examined in a report of proceedings now available both electronically and in paper copy from the National Institute for Occupational Safety and Health (NIOSH).
"Use of Workers’ Compensation Data for Prevention of Occupational Injuries and Illnesses: Proceedings from September 2009 Workshop," DHHS (NIOSH) Publication No. 2010-152, is posted at http://www.cdc.gov/niosh/docs/2010-152/pdfs/2010-152.pdf Adobe PDF file. The 2009 workshop was co-sponsored by NIOSH, the Bureau of Labor Statistics, the National Council for Compensation Insurance, and the Washington State Department of Labor and Industries’ Safety and Health Assessment and Research for Prevention Program.
"As researchers and practitioners seek innovative means to improve the surveillance of occupational injuries and illnesses, workers’ compensation data offer a potentially useful answer - but the limitations and uncertainties of those data must be addressed," said NIOSH Director John Howard, M.D. "We are pleased to offer these proceedings as a unique resource for assessing current uses of workers’ compensation information for health surveillance, suggesting new uses, and engaging the uncertainties that we face in doing so."
Although workers’ compensation programs record cases of occupational injury and illness that have already occurred, they generate data that may also serve useful purposes for preventing future injuries and illnesses. Those data may provide insights into the severity of cases, recent trends, and emerging concerns that other data sources may not.
However, several factors pose difficulties for using workers’ compensation records as a surveillance and research resource. Because different states have different rules on compensability and because data are not always coded according to a standard system, it may be difficult to harmonize and interpret data nationally. Where larger data sets exist, they generally are proprietary, and access is restricted beyond the purposes for which they were originally established.
The proceedings include more than 30 prepared presentations and a summary from the workshop. Nearly 80 participants from federal and state agencies, labor, academia, and the insurance industry made presentations and engaged in discussions.

Monday, October 18, 2010

The Toxic Contamination of North Jersey


In a recent report in the The Record it was noted that hundreds of toxic sites were located in North New Jersey, specifically Bergen and Passaic counties. The former geographical location of the Industrial Revolution, the area was the home of many manufacturing facilities and in close proximity of the Great Falls of Paterson NJ. The Society of Useful Manufacturers was established by Alexander Hamilton at the base of the Passaic River in Paterson NJ.

The manufacturing facilities left a legacy of toxic pollution and a lot of that pollution migrated into the Passaic River and flowed downstream to from Passaic County to Bergen County. Toxic sites proliferate the area and an epidemic of industrially produced disease remains from the occupational exposures and the bystander exposures.

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

Wednesday, October 13, 2010

NJ Denies an Occupational Workers Compensation For Last Exposure Applying Apportionment Rule

A NJ Appellate Court denied an employee workers' compensation benefits by applying an apportionment rule as well as the manifestation of disease doctrine. The employee worked in two states and spend more than 10 times of his working career in Pennsylvania working n a similar job during which time manifestation occurred.


"We do not suggest that there is a mandatory mathematical formula that judges of compensation should apply in calculating the employment exposure of a petitioner as part of Williams's jurisdictional test. Although we might quibble with Judge LaBoy's description of petitioner's exposure as "de minimis," we nevertheless conclude that the sixteen-month exposure was not sufficiently substantial under the totality of the circumstances to constitute injury-conferring jurisdiction in the Division."


McGlinsey v George H. Buchanan Company, Not Reported in A.3d, 2010 WL 3932983 (N.J.Super.A.D.) Decided September 30, 2010


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.
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Sunday, October 10, 2010

Cell Phone Safety and Workers Compensation

Workers' Compensation benefits may soon be denied to employees involved in motor vehicle accidents because of the unauthorized use of cell phones while driving within the course of their employment. As the US Department of Transportation (USDOT) continues to educate Americans with overwhelming statistical evidence that distracted driving is a major cause of accident, the denial of benefits to cell phone users may become a major incentive to create a safer work environment.

Meanwhile, the US Department of Transportation is leaning toward banning all use of cell phones by drivers. At the second national USDOT summit on the increased hazards of the use of cell technology  a major campaign was launched to encourage employers to outright  ban the use of cell phones by employees while working.

Employers have become increasingly concerned over employee "cognitive distraction" caused by the use of cell phones in motor vehicles as more data has become available associating driver cell phone use with accidents. Methods of enforcement will include the use of traffic cameras as the system already hss the capability of detecting drivers who are using telephones while driving. Evidentially, telephone billing records produced post accident can be used to corroborate the fact that an employee was using a telephone while working.

The precedent of using the workers compensation acts to make occupational environments safer is already established. The denial of workers' compensation benefits for unsafe actions by employees has previously been incorporated into law and has been an economic incentively for employers to reduce costs. Employees who are under the influence of drugs or alcohol, and those who fail to use employer provided safety devices, have already been denied benefits in some jurisdictions.

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.

Saturday, October 9, 2010

RICO Case Dismissed By Trial Court After US Supreme Court Decision

A Federal District Court in Michigan has dismissed a RICO [Racketeer Influenced and Corrupt Organizations Act] claim against Cassens Transportation Company and several other defendants. This is the third time the case was negatively reviewed by the US District Court in Michigan and follows a landmark decision in the US Supreme Court supporting the RICO action that flowed from an underlying  by a workers' compensation action.

"The Court concludes that Plaintiffs' exclusive remedy for their claim that they were fraudulently denied benefits under the WDCA [Workers' Disability Compensation Act] lies within the exclusive administrative scheme set forth in the WDCA which forcloses their RICO claim."

Brown v Cassens Transportation Company, et al. No. 04-cv-72316, 2010 WL 3842373, Decided Sept. 27, 2010.

Click here to read more about RICO claims and workers' compensation.

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.