New Jersey Hospital Attorney
Health Insurance Audits
No-Fault Insurance aka Personal Injury Protection (PIP)
Hospitals see a large number of automobile accident victims in their emergency rooms. As your hospital’s billing department will no doubt attest, navigating the convoluted world of No-fault reimbursement (also called PIP), can be a thorny proposition. There are a number of pitfalls that can arise in recovering payment from PIP insurers. Even where coverage is not an issue, a PIP insurer will seize upon every opportunity to slash and cut reimbursement, even when the auto carrier’s actions are contrary to New Jersey law or existing contractual arrangements. We have successfully disputed and recovered additional reimbursement from auto carriers under the following circumstances:
Improper application of the Physician’s Fee Schedule, which does not apply to hospitals or Hospital Outpatient Surgical Facility Fee Schedule (HOSF) which does not apply to emergency room treatment;
Improper reduction of billed charges for inpatient treatment (which is exempt from the No-Fault regulatory framework governing reimbursement;“ Usual and customary” reductions based upon dubious fee data; and improper application of existing network or PPO agreements.
Similar to auto accidents, hospitals see a number of trauma and emergency patients as a result of workplace injuries. The New Jersey Workers Compensation system has no “fee schedule” to govern reimbursement to medical providers, including hospitals, for treatment and services provided to workers injured on the job. Unless the hospital has a contractual arrangement through a network or PPO that includes the Workers Compensation insurer as a designated payor, the hospital is entitled to receive payment at its usual and customary rates. Even when a network agreement is applicable, the Workers Compensation carrier may apply the contract rates incorrectly, or cut out reimbursement wherever it believes it can get away with it through some creative auditing techniques.
Major medical insurance carriers, in addition to improper utilization management denials, will pursue any means, be it penalty, “cross-walk,” “downcode” or the like, to reduce overall reimbursement to your facility. In addition to pursuing all remedies to maximize your reimbursement under major medical plans, the Costello Law Firm can assist you with insurance audits and investigations, re-payment demands, and improper application of a network or PPO agreement.