Proposed Changes to Guidelines for Medical Provider Claims in New Jersey

Insurance carriers and medical providers have a longstanding history of disputes concerning the appropriate payment for medical treatment rendered to workers’ compensation petitioners. N.J.S.A. 34:15-15 states in relevant part that “[a]ll fees and other charges for such physicians’ and surgeons’ treatment and hospital treatment shall be reasonable and based upon the usual fees and charges which prevail in the same community for similar physicians, surgeons, and hospitals services.” Consequently, Medical Provider Applications were created in New Jersey to provide a means to give all interested parties a way to address these disputes as efficiently, quickly and fairly as possible. However, there is a lack of consistency on how Medical Provider Applications are handled through the discovery and pre-trial phase of litigation.

Recently, the Medical Provider Claim Task Force proposed guidelines that would create uniformity and consistency to the litigation process relating to these types of claims. The initial filing of the pleadings would remain the same. However, the proposed guidelines would require that, within 30 days of the filing of a medical provider claim, the medical provider or applicant must file with the court and serve upon the respondent party the following documentation:

1. Certification that the medical provider has served upon the respondent all its charges for all dates of service and procedures that are in dispute;
2. Certification or documentation that the provider has complied with the respondent’s/carrier’s internal appeals process or request for reconsideration and responses, if any;
3. A statement addressing whether the medical provider is within network, a panel physician or whether there is a network dispute with the carrier;
4. A statement of the exact amount of payments made by the carrier to date in conjunction with the proffered bills, and a statement of explanation addressing any coding disputes; and
5. The corresponding medical treatment records, health insurance claim forms (such as HCFA or UB), any explanation of benefits or reimbursements (EOBs or EORs), the type of facility where the service or procedure was preformed, and any explanation of how the provider derived its fee schedule.

This documentation must be provided by the medical provider for each claim filed with the Division of Workers’ Compensation within 30 days of filing a Medical Provider Claim. The idea is to make the medical provider fully exhaust every remedy for obtaining payment before the onset of litigation. This will also help clarify what type of payment dispute the Medical Provider Claim is asserting.

Upon receipt of this documentation, along with a filed Medical Provider Application, the Division may order the respondent to provide the following proofs:

1. Confirmation that the EOBs and EORs filed by the applicant were true/accurate copies;
2. A statement of explanation addressing any coding disputes, or the level of reimbursement only if that is the sole issue, and/or other issues such as compensability or unauthorized treatment; and
3. Any other proofs in support of its position that usual and customary reimbursement on charges were or were not paid by the carrier or its agents.

These procedures would not be automatically applicable. Rather, it will be up to the court’s discretion to order that the documentation be provided by the respondent.

Parties may propound and exchange medical claim provider interrogatories within 30 days of the filing of respondent’s answer. The time to answer interrogatories would be expanded from 45 days to 60 days of their receipt. All parties would also be required to file with the court data points or evidence of UCR payments (usual, customary and reasonable) showing paid amounts for each CPT code at issue. Also, these data points are not to be limited, but must include reimbursements for the relevant codes made under New Jersey Personal Injury Protection Fee Statute, and any other probative evidence of paid charges received and accepted by the medical provider or paid by the carrier.

At the pre-trial litigation stage, the judge will review all submissions by the provider and the respondent. The court will have discretion to allow each party to supplement insufficient proofs within a reasonable amount of time. However, if the proofs are not provided within the time period ordered by the court, the respondent may request a “Not Moved” marking from the court. Accordingly, respondents will be able to file a motion to dismiss for lack of prosecution based upon the medical provider’s failure to comply with discovery demands.

These proposed changes were created to supplement the current Division rules in order to simplify the discovery process and ensure litigants meet their respective burdens of proof. Furthermore, New Jersey Division of Workers’ Compensation Judges will be able to obtain all necessary evidence in order to make accurate findings and holdings for each claim litigated. This supplement would be very beneficial to insurance carriers, although these are merely proposed changes to the current law. It would create rigid guidelines for medical providers to follow and also provide a clear dismissal remedy to respondents if their discovery demands are not complied with. The hope is that medical providers will be forced to follow the correct procedures for obtaining payments for their services and fully exhaust all processes and remedies before filing medical provider claims in court.

The full memorandum for the Proposed Guidelines for Medical Claims by Providers by the Medical Provider Claim Task Force can be found at the following link: http://lwd.dol.state.nj.us/labor/wc/content/notices.html#MPC_120914.

*Rachel is an associate in our Roseland, New Jersey office who can be reached at 973.618.4161 or ralowe@mdwcg.com.

_{Defense Digest, Vol. 21, No. 2, June 2015}

_{Defense Digest is prepared by Marshall Dennehey Warner Coleman & Goggin to provide information on recent legal developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. Copyright © 2015 Marshall Dennehey Warner Coleman & Goggin, all rights reserved. This article may not be reprinted without the express written permission of our firm.}