New Jersey’s Personal Injury Protection auto insurance system can be confusing, frustrating, and costly for all health care providers. Moreover, as a medical professional, getting fully paid by insurers has never been more frustrating nor time consuming. The Khorozian Law Group is here to help you navigate this complex system at absolutely no cost to you, EVER.
The Khorozian Law Group can help you receive payment for services rendered to patients under New Jersey’s no-fault auto insurance laws through the PIP arbitration process.
PIP is a package of insurance benefits which include medical expense benefits, income continuation benefits, essential service benefits, funeral benefits and death benefits. Medical expense benefits are hospital, medical, and related expenses incurred for treatment of injuries.
In New Jersey, PIP Arbitrations are the mechanism set up by the New Jersey Department of Insurance to resolve disputes between Medical Providers and Automobile Insurance Companies. Medical providers who treat automobile accident victims are eligible to have all bills paid pursuant to their usual, customary and reasonable rate or the New Jersey PIP Fee Schedule, N.J.A.C. 11:3-29.6. If bills are unpaid or underpaid by the PIP carrier, Khorozian Law Group can obtain payment directly from the insurer by filing a PIP arbitration with Forthright Solutions. The Arbitration Proceedings are decided by Forthright Solutions’s appointed arbitrators of the disputes. These proceedings are governed by Rules (Amended Rules – Effective April 15, 2013 NEW ) set up by Forthright as approved by the Department of Insurance and Banking.
By way of overview of the process, most medical treatment must be PreCertified by the PIP Insurer to be payable without dispute. If the Insurer denies treatment after a Precertification Request it is still payable if it is determined that the treatment was in fact medically necessary. Although it should be noted that a failure to Pre-certify may result in a 50 % penalty even if the treatment is found to be medically necessary. All billing must be submitted using Current Procedure Terminology Codes (CPT) (Automobile Medical Fee Schedule). Once a bill is submitted to the Insurer they will consider payment and they will issue an Explanation of Benefits (EOB) letter. If payment is denied an Arbitration is required to compel payment. To initiate the arbitration process, a Demand needs to be sent to Forthright Solutions with a filing fee. Eventually, a Dispute Resolution Professional (DRP) is appointed and an in–person hearing is conducted (unless pursuant to the Rules the Claimant requests a ruling on the papers). Once a decision is made there is a limited right to appeal the Arbitrator’s Ruling in the New Jersey Superior Court.
Some common defenses to deny payment are as follows: the patient afield to cooperate with the insurer; the patient is not eligible for coverage; pre-certification was not requested; the patient utilized an out of network facility; the service was not medically necessary; the policy limits were exhausted; the wrong billing codes were utilized; the facility did not provide adequate documentation; the facility did not comply with billing regulations;
In addition, to filing a demand for arbitration for services that have already been rendered, pursuant to N.J.A.C. 11:3-5.4(b) 6, if an insurer denies approval for medical treatment or testing as not medically necessary and the treatment or testing has not occurred, then the injured person or his/her health care provider may request an expedited determination of medical necessity by a Medical Review Organization (“MRO”) for future treatment.
Khorozian Law Group prides itself on constant communication with the medical providers, keeping them abreast of the status of their cases from the initial appeal process to settlement and payment of the claim. In addition, Khorozian Law Group reviews your files to make sure all the necessary documentation has been provided in order to maintain the firm’s 95% success rate. There is absolutely no fee to the provider for the firm’s legal services and fees. Moreover, Khorozian Law Group does file New Jersey Property-Liability Insurance Guaranty Association (NJ PLIGA) cases. We also assist the provider in the appeals process so that we can ensure the firm’s high success rates.
Contact Khorozian Law Group with any questions or to set up a consultation.