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New Jersey PIP Arbitration: How a Medical Provider Can Maximize the Odds of Winning

New Jersey PIP Arbitration Attorney

Submitting the proper documentation is essential to maximizing the odds of winning any PIP Arbitration. There are several issues that are commonly the subject of PIP Arbitration. However, medical necessity and causation are the two most common issues. In order to be successful on these issues (and others), it is extremely important that the provider’s PIP Arbitration lawyer have the following documentation:

1/5: Assignment of Benefits

Most providers already require that the patient sign an assignment of benefits form in order for the provider to receive insurance payments directly. This form is also necessary to file a PIP arbitration on behalf of the provider. Recently, many insurance companies have been contesting the validity of the provider’s assignment of benefits.

What is required for an assignment of benefits to be valid? A valid assignment must contain clear evidence of the intent to transfer the person’s rights and the subject matter (e.g. PIP Claim) of the assignment must be described sufficiently to make it capable of being readily identified. The assignment must be clear and unequivocal in order to be effective as to the obligor. Therefore, it is very important that the PIP Arbitration have the assignment of benefits and that it be valid in order to maximize the odds of winning at arbitration.

2/5: Bills

Obviously, the bills are essential to any PIP Arbitration. However, it is important that the provider’s PIP Arbitration attorney possess both the Health Insurance Claim Forms (“HCFAs”) and the Explanations of Benefits (“EOBs”) for the outstanding dates of service. Providing only an itemized billing statement, for example, may prevent or lessen the amount of recovery at arbitration. Frequently, the amount outstanding on the itemized billing statement differs from what the insurance company asserts is outstanding. Therefore, the analysis must occur that requires comparing the HCFAs to the EOBs. If the itemized billing is incomplete (e.g. there are no CPT codes), then it will be difficult or impossible to prove the case to the arbitrator.

3/5: Treatment (S.O.A.P) Notes & Examination Reports

Whenever the issue is medical necessity or causation, all of these documents are potentially vital to winning at arbitration. Many times, providers will only submit the treatment notes and re-examination reports for the outstanding dates of service. This is not a good idea. If, for example, the insurance company is asserting that the injury is not causally related to the accident, a re-examination report five months after the date of the accident, while unpaid, would not be particularly helpful and may prevent the provider from prevailing at arbitration. Under this scenario, the initial examination report becomes perhaps the most important document. Therefore, as a general rule, it is better to submit all of the treatment notes, the initial examination report and all of the re-examination reports to the PIP Arbitration attorney. Then, the attorney should then determine which of these documents are relevant to the issues identified for arbitration.

4/5: Pre-Certification Requests

Clearly, the pre-certification requests are necessary where the issue is failure to pre-certify the treatment. However, even where there is no issue as to whether the provider submitted a proper and timely pre-certification request, it is important to provide all of the pre-certification requests with the fax confirmation pages to the PIP Arbitration lawyer. Why is it important to provide the PIP Arbitration with the Pre-Certification requests? There are several reasons; however, one reason in particular is that the peer review doctor may not have reviewed all of the documentation or misconstrued what the doctor submitted with the pre-certification request. If the peer review doctor did not review all of the documents submitted with the pre-certification request or misconstrued it, then his or her opinion as to the medical necessity of treatment is inadequate. When this happens, the provider’s odds of winning at arbitration increase dramatically.

5/5: Appeals

Pre and Post Service Appeals – Before the recent changes in the PIP rules, these documents were important to uphold the validity of the assignment of benefits. Now, they are necessary to even file a PIP Arbitration. Therefore, it is important that all treatment denials and all billing denials be timely appealed prior to filing a PIP Arbitration and submitted to the PIP Arbitration attorney.

If you are a medical provider that is not happy with your PIP Arbitration results, it may be because the proper documentation has not been submitted for arbitration. Submitting these documents for arbitration will greatly help in maximizing the odds of winning a PIP Arbitration.

Thank you for reading. If you have any questions about New Jersey PIP Arbitration, please do not hesitate to contact The Sloan Law Firm at: (908) 358-2938 or dsloan@sloanlawfirmnj.com.