John R. Moeller, Jr., P.C.
PIP Benefits Defined
In the state of New Jersey, if one is involved in a motor vehicle accident, they are typically entitled to PIP benefits from any one of a number of auto insurance policies, including the host vehicle as well as that of the named insured.
An initial determination has to be made as to which policy is primary.
Should you have any questions or would like this office to assist your practice with compelling payment from No-Fault carriers via Arbitration, please do not hesitate to contact us below:
JOHN R. MOELLER, JR., P.C.
Brielle Hills Professional Park
2640 Highway 70
Building 7, Suite 102
Manasquan, New Jersey 08736
Phone: (732) 899-5995
Fax: (732) 899-5899
PIP benefits are a statutorily created array of benefits, which include medical expense benefits. In particular, these medical expense benefits are defined as reasonable hospital, medical and related expenses incurred for the treatment of auto related injuries. Coverage includes benefits for inpatient and outpatient hospital visits, doctors, chiropractors, chiropractors, dentists, psychologists, therapists, skilled nursing care, prescriptions, appliances, diagnostic tests such as x-rays, MRIs and the like. The standard PIP policy has a $250.00 deductible and a 20% co-payment for the first $5,000.00 in medical expenses.
Once the bills reach $5,000.00, the typical New Jersey automobile policy will make full payment of all medical expenses, up to $250,000.00.
It should be kept in mind that medical expenses are subject to a fee schedule developed by the New Jersey Department of Insurance, which provides reimbursement rates for various procedures.
Medical providers are prohibited from balance billing patients for any fees in excess of that prescribed by the New Jersey Fee Schedule.
If a procedure is not listed on the New Jersey Fee Schedules we attempt to establish the usual and customary charge of that particular medical service. This is often done by providing Explanation of Benefits (EOBs), establishing what the provider typically receives from other insurance companies for the same procedure.
Our offices are typically asked to arbitrate a claim when an insurance carrier refuses to pay a medical provider. The basis for denial of PIP benefits can vary and include: lack of medical necessity, failure to pre-certify, failure to appeal a denial to request pre-certification, lack of coverage and the like. Typically, medical necessity is disputed by doctors hired by the insurance companies. Invariably, the insurance company doctors conclude that the treatment is not medically necessary, or will not result in additional improvement. However, as a treating physician, there is certainly no obligation to accept the decision of the doctor hired by the insurance company. Generally, a treating physician is in a much better position to determine what care his or her patients require and as along as the treating physician is willing to provide support for its opinion, that ongoing care is necessary and will benefit the patient, we are generally successful in resolving or arbitrating claims for continued treatment.
In the event we assume representation of a medical provider, we advance all costs in connection with the filing of the Demand for Arbitration, which includes a $225.00 filing fee. Additionally, reimbursement of these costs, as well as our legal fee, will be paid by the automobile insurance so there are never any costs or legal fees requested from our clients.
Familiarizing your office staff with the New Jersey PIP system can allow your practice to accept more PIP patients.
The Department of Banking and Insurance (DOBI) Bulletin No. 10-30
In the past, we have successfully argued that as long as the claim has been appealed prior to Arbitration, this should suffice to allow the matter to proceed to Arbitration. Arbitrators have agreed with this position stating essentially than an insurer may not circumvent the binding Arbitration process by requiring unreasonably burdensome procedures to be followed prior to Arbitration. Other Arbitrators have determined that the maximum penalty for failing to follow an internal appeal requirement is a 50% penalty while still other Arbitrators have determined that as long as the internal appeals process is substantially complied with, there is no basis to preclude Arbitration.
The DOBI Bulletin No. 10-30 as prepared by the Insurance Commissioner Thomas B. Considine suggests that providers must comply with all requirement of the Decision Point Review Plan prior to initiation of PIP Arbitration, including time limits on appeals. Other examples may include a requirement that additional supporting documentation accompany an appeal or that the appeal be signed by the treating physician.
Since its publication, insurers have relied upon the Bulletin from the Commissioner of Insurance to defend PIP Arbitrations which have not been properly and/or timely appealed. For that reason, it is important that medical providers follow the various appeal procedures as contained within the insurance companies’ Decision Point Review Plan.
Every effort should be made to comply with the various Decision Point Review Plans including compliance with these time limits contained in each Decision Point Review Plan so as to avoid a potential complete denial of benefits and/or dismissal of Arbitration.