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PIP Arb Example

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C. Kevin Grim Jr., Esq.

This letter details medical billing charges owed by an insurance company totaling over $20,000. It lists numerous chiropractic treatments, examinations, and manipulations provided to a patient from October 2011 to August 2012. It asserts the insurance company failed to provide proper notice and improperly denied claims. A demand is made for payment of all outstanding balances according to the fee schedule.

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January x, 20xx Via Website Upload Justice 000 Summerville Avenue, Suite 000 Westfield, NJ 00000 Attn: Robert Stark Re: Chiropractic Center a/s/o John Smith v. Big Insurance Group Forthright File No.: xxxxxxxxxxxxxx Insurance Claim No.: xxxxxxxxxxxxxxxxxx Respondent File No.: xxxxxxxx Our File No.: xxxx D/A: xx/xx/xx Dear Mr. Stark: Please accept this letter in lieu of a more formal brief on behalf of the Claimant as our pre-hearing submission. The following demand balance, as per fee schedule, is due upon determination of failure to notice of EUO, failure to notice of IME, 72-hour rule, improper application of pre- certification penalty, medical necessity and under/nonpayment: DOS CPT/Procedures Amount Billed Amount Paid Amount Owed 10/19/11 99204 – Initial Exam $153.97 $0.00 $153.97 10/19/11 E1399 – Cervical Pillow $35.00 $0.00 $35.00 10/19/11 99070 – Pain Gel $30.00 $0.00 $30.00 10/19/11 E0230 – Ice Pack $25.00 $0.00 $7.88 10/19/11 97124, 97012, 97032 $80.28 $0.00 $80.28 10/21/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 10/24/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 10/26/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00
Forthright No.: 1477174 July 11, 2015 Page 2 of12 10/28/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 10/31/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/02/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/04/11 72052 – X-Ray $127.81 $0.00 $127.81 11/04/11 72070 – X-Ray $80.87 $0.00 $80.87 11/04/11 72110 – X-Ray $111.08 $0.00 $111.08 11/04/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/07/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/09/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/11/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/14/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/16/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/18/11 99213 - 25 Office Exam $59.87 $0.00 $59.87 11/18/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/21/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/23/11 E0215 – Electric Heat Pad $60.21 $0.00 $60.21 11/23/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/25/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/28/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/30/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 12/02/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/05/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/07/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/09/11 99213 - 25 Office Exam $59.87 $0.00 $59.87 12/09/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/12/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/14/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/16/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/19/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/21/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/23/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/26/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/28/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/30/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/02/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/04/12 97750 59 - 16 Units $808.96 $0.00 $808.96 01/04/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/06/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/09/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 01/09/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 06/13/12 99213 - 25 Office Exam $59.87 $0.00 $59.87
Forthright No.: 1477174 July 11, 2015 Page 3 of12 06/13/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/15/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/18/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/20/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/22/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/25/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/27/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/29/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/02/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 07/02/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/06/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/09/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/11/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/13/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/16/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/18/12 95831 - 4 Units $170.88 $0.00 $170.88 07/18/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/20/12 95851 - 4 Units $138.36 $0.00 $138.36 07/20/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/23/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/25/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/27/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/30/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/01/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/03/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 First MUA Procedure 08/03/12 22505 MUA - Spine $3,600.00 $0.00 $197.57 08/03/12 23700 50 MUA - LT Shoulder $1,200.00 $0.00 $327.09 08/03/12 23700 50 MUA - RT Shoulder $1,200.00 $0.00 $163.55 08/03/12 27275 50 MUA - LT Hip $1,200.00 $0.00 $304.43 08/03/12 27275 50 MUA - RT Hip $1,200.00 $0.00 $152.22 08/03/12 27194 50 MUA - Pelvis $2,400.00 $0.00 $2,400.00 First MUA Procedure, 20% due for Assistant 08/03/12 22505 - 62 MUA - Spine $720.00 $0.00 $39.51 08/03/12 23700 - 62 LT Shoulder $240.00 $0.00 $65.42 08/03/12 23700 - 62 RT Shoulder $240.00 $0.00 $32.71 08/03/12 27275 - 62 LT Hip $240.00 $0.00 $60.89
Forthright No.: 1477174 July 11, 2015 Page 4 of12 08/03/12 27275 - 62 RT Hip $240.00 $0.00 $30.45 08/03/12 27194 - 62 50 Pelvis $480.00 $0.00 $480.00 08/06/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 08/06/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/08/12 95831 - 4 Units $170.88 $0.00 $170.88 08/08/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 Second MUA Procedure 08/10/12 22505 MUA - Spine $3,600.00 $0.00 $197.57 08/10/12 23700 50 MUA - LT Shoulder $1,200.00 $0.00 $327.09 08/10/12 23700 50 MUA - RT Shoulder $1,200.00 $0.00 $163.55 08/10/12 27275 50 MUA - LT Hip $1,200.00 $0.00 $304.43 08/10/12 27275 50 MUA - RT Hip $1,200.00 $0.00 $152.22 08/10/12 27194 50 MUA - Pelvis $2,400.00 $0.00 $2,400.00 Second MUA Procedure, 20% due for Assistant 08/10/12 22505 - 62 MUA - Spine $720.00 $0.00 $39.51 08/10/12 23700 - 62 LT Shoulder $240.00 $0.00 $65.42 08/10/12 23700 - 62 RT Shoulder $240.00 $0.00 $32.71 08/10/12 27275 - 62 LT Hip $240.00 $0.00 $60.89 08/10/12 27275 - 62 RT Hip $240.00 $0.00 $30.45 08/10/12 27194 - 62 50 Pelvis $480.00 $0.00 $480.00 08/10/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 08/10/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/13/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/15/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/17/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 08/17/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 Third MUA Procedure 08/17/12 22505 MUA - Spine $3,600.00 $0.00 $197.57 08/17/12 23700 50 MUA - LT Shoulder $1,200.00 $0.00 $327.09 08/17/12 23700 50 MUA - RT Shoulder $1,200.00 $0.00 $163.55 08/17/12 27275 50 MUA - LT Hip $1,200.00 $0.00 $304.43 08/17/12 27275 50 MUA - RT Hip $1,200.00 $0.00 $152.22 08/17/12 27194 50 MUA - Pelvis $2,400.00 $0.00 $2,400.00
Forthright No.: 1477174 July 11, 2015 Page 5 of12 Third MUA Procedure, 20% due for Assistant 08/17/12 22505 - 62 MUA - Spine $720.00 $0.00 $39.51 08/17/12 23700 - 62 LT Shoulder $240.00 $0.00 $65.42 08/17/12 23700 - 62 RT Shoulder $240.00 $0.00 $32.71 08/17/12 27275 - 62 LT Hip $240.00 $0.00 $60.89 08/17/12 27275 - 62 RT Hip $240.00 $0.00 $30.45 08/17/12 27194 - 62 50 Pelvis $480.00 $0.00 $480.00 08/20/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/22/12 L0976 – Lumbar Belt $120.96 $0.00 $120.96 08/22/12 E0855 – Cervical Pump $502.63 $0.00 $502.63 08/22/12 97535 – Home Instructions $37.85 $0.00 $37.85 08/22/12 E0730 – Tens Unit $400.00 $0.00 $400.00 08/22/12 97535 – Home Instructions $37.85 $0.00 $37.85 08/22/12 A4630 Battery – 6 $33.66 $0.00 $33.66 08/22/12 A4556 Electrodes Pair – 6 $179.40 $0.00 $179.40 08/22/12 A4557 Lead Wires - 2 $35.88 $0.00 $35.88 08/22/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/24/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/27/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/29/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/31/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/05/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/07/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/10/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/12/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 09/12/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/14/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/17/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/19/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/21/12 97750 59 - 16 Units $808.96 $0.00 $808.96 09/21/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/24/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/26/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/28/12 95831 - 4 Units $170.88 $0.00 $170.88 09/28/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/01/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/03/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/05/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/08/12 98941, 97110, 97530 $145.37 $0.00 $99.00
Forthright No.: 1477174 July 11, 2015 Page 6 of12 10/10/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/12/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/15/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/17/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/19/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/22/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 10/22/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/24/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/26/12 95831 - 4 Units $170.88 $0.00 $170.88 10/26/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/05/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/07/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/09/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/12/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/14/12 95851 - 4 Units $138.36 $0.00 $138.36 11/14/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/16/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/16/12 99213 - 25 Discharge $59.87 $0.00 $59.87 Total Due: $27,735.58 The Patient’s Failure to Attend the EUO does not Rise to the Level of Egregious as Respondent failed to properly notice the patient’s Attorney In regard to Examinations Under Oath (EUO), N.J.A.F.I.U.A. v. Jallah, 256 N.J. Super 134 (App. Div 1992) is a governing case on auto insurance policy cooperation. Jallah dealt with a dismissal of a claim as a result of a failure to cooperate by not attending a statement under oath. The court held that a dismissal of an otherwise deserving claim for failure to submit to discovery should be reserved for egregious breaches of an insured’s failure to cooperate. The court referred to a dismissal of benefits as a “draconian remedy” Id. at 142. It is well settled that the right to conduct an examination under oath (EUO) is not absolute and unfettered. At the very least, it is circumscribed by ordinary standards of reasonableness and fairness. Prudential Prop. & Cas. v. Nardone 332 N.J. Super 126 (Law Div 2000). Respondent claims Mr. John Smith missed two examinations under oath (EUOs) scheduled on January x, 20xx and March x, 20xx. However, the record demonstrates Respondent failed to notify Mr. Smith via his attorney, Rudy Baylor. In addition, it appears Respondent’s EUO scheduling letters were for a Paul Doe, who
Forthright No.: 1477174 July 11, 2015 Page 7 of12 was represented by Mr. Vincent Gambini, Esq. (see Exhibit C from Respondent’s November x, 20xx submission). These letters do not mention John Smith. On January x, 20xx, Respondent sent one (1) EUO scheduling letter to an attorney by the name of Mr. Atticus Finch for John Smith (see Exhibit C from Respondent’s December x, 20xx submission). However, on November x, 20xx, Mr. Jake Brigance wrote a letter to Respondent, Big Insurance Group (BIG), notifying them that his office, Houseman & Baylor, was now representing Mr. Smith in regards to his October x, 20xx accident (see Exhibit A). According to Jallah, dismissal of benefits is a draconian remedy reserved for egregious breaches. The evidence presented does not rise to level of an “egregious breach” on behalf of the patient as Respondent failed to notice to Mr. Smith’s attorney Rudy Baylor for the EUO. Furthermore, Claimant asserts the mere basis that Mr. Smith was a passenger in a host vehicle is not sufficient to deny coverage. Respondent has not articulated any suspicion of fraud to justify an EUO. Respondent has also failed to identify any other PIP policy in which they felt Mr. Smith had coverage under. Respondent’s actions were unreasonable and PIP benefits should not be denied for the improper notice of the EUO. Respondent’s Failure to Notice the Treating Provider of the IME violates N.J.A.C. 11:3- 4.7(e)(1) & (7) In regard to the Independent Medical Examination (IME) request, applicable case law has included IME as “discovery” under Jallah. Respondent claims Mr. John Smith missed two unexcused independent medical exams (IMEs) appointments scheduled on December x, 20xx and December x, 20xx. Once again, the IME scheduling notices were sent to the wrong attorney, Atticus Finch (see Respondent’s December x, 20xx submission, IME scheduling letters). It also appears Chiropractic Center was not noticed on any of the IME scheduling letters either. In accordance with N.J.A.C. 11:3-4.7(e)(1) which reads, in pertinent part, as follows: “The insurer shall notify the injured person or his or her designee that a physical examination is required to determine the medical necessity of further treatment, diagnostic tests or durable medical equipment. An insurer shall include reasonable procedures for the notification of the injured person and the treating medical provider where reimbursement of the further
Forthright No.: 1477174 July 11, 2015 Page 8 of12 treatment, diagnostic testing or durable medical equipment will be denied for failure to appear at scheduled medical examinations.” Additionally, N.J.A.C. 11:3-4.7(e)(7) reads, in pertinent part, as follows: “Insurers may include in their decision point review plan a procedure for the denial or reimbursement for treatment, diagnostic testing or durable medical equipment after repeated unexcused failure to attend a scheduled physical examination. The procedure shall provide for adequate notification of the insured and the treating provider of the consequences of failure to attend the examination.” Claimant asserts the scheduling of the IME’s without notice to the patient’s attorney or Chiropractic Center violates the dictates of N.J.A.C. 11:3-4.7(e)(1) and (7). All IME correspondence post-dates the November x, 20xx letter of representation from the office of Houseman & Baylor (see Exhibit A). Failure to Attend the IME only bars payment of future treatment Nevertheless, should the DRP find the IME was properly noticed, Claimant asserts Respondent’s DPR Plan only allows for future medical expense benefits to be denied. Respondent’s Decision Point Review states “If there is more than one unexcused failures to attend the scheduled exam, notification will be immediately sent…The notification will place the parties on notice that all future treatment…will not be reimbursable as a consequence of failing to comply with the plan” (emphasis added) (see Exhibit D of Respondent’s December 5, 2013 submission). It does not appear Respondent ever sent proper notice to the medical provider that PIP benefits would be terminated for failure to attend the IME. Claimant respectfully requests the DRP award PIP benefits based on Respondent’s violation of N.J.A.C. 11:3-4.7(e)(1) and (7). Pre-certification Compliance N.J.A.C. 11:3-4.4(e) states in part, “Failure to request decision point review or pre-certification where required or failure to provide clinically supported findings that support the treatment…shall result in an additional co-payment not to exceed 50 percent…” Respondent alleges that Claimant Provider only made two (2) pre-certification requests for the entire course of chiropractic treatment; those being for DOS October x, 20xx to December x, 20xx and January x, 20xx to February x, 20xx. Respondent is incorrect.
Forthright No.: 1xxxxxx July 11, 2015xx Page 9 of12 Claimant submits proof of pre-certification from October x, 20xx to December x, 20xx, from January x, 20xx to February x, 20xx, and from June x, 20xx to October x, 20xx (see Exhibit B), therefore, the 50% per-certification penalty applied by Respondent is improper. Substantial Compliance with Pre-certification Claimant asserts substantial compliance for the dates of service October x, 20xx to December x, 20xx (see Exhibit B). Provider Chiropractic Center (CC) requested the same or similar codes several times throughout the course of treatment and Respondent had knowledge of the several dates the codes were requested and made partial payment. Respondent now attempts to benefit from a technicality by applying the pre-certification penalty to codes that fell a few days outside the requested date range. The pre-certification penalty is supposed to be applied only when a provided treatment was neither requested nor supported with documentation, not to punish patients and providers based upon a technicality. Therefore, the 50% penalty was not proper. Claimant asserts the evidence supports sufficient to compliance with N.J.A.C. 11:3-4.4 and N.J.A.C. 11:3-4.7. As Respondent claims they did not receive the pre-certification request and Claimant has supplied proof (see Exhibit B), Claimant must present the following 72-hour rule violation claim. 72 Hour rule violation In Coalition for Qaulity Health Care v. NJ DOBI, 348 NJ Super 272, 306 to 308 (App. Div. 2002), the Court held that, for care path injuries, if the carrier does not respond to a Decision Point Review notice within the prescribed time period (3 business days), the treatment/testing may continue and is deemed approved. N.J.A.C. 11:3-4.7(c)(4) requires a response to either a Decision Point Review or pre-certification notice within 3 business days. Furthermore, N.J.A.C. 11:3-4.7(g) confirms that the failure of a carrier to respond to such notice is considered approval for the requested services. Claimant asserts a delayed response to the treatment was provided by Respondent in violation of the 72 Hour Rule. Claimant submitted pre-certification requests dated from October x, 20xx to December x, 20xx, from January x, 20xx to February x, 20xx, and from June x, 20xx to October x, 20xx (see Exhibit B).
Forthright No.: 1xxxxxx July 11, 2015xx Page 10 of12 It appears Respondent has not submitted any proof that they responded in a timely fashion. Claimant asserts Respondent is barred from arguing medical necessity as they violated N.J.A.C. 11:3. In the instance, Respondent submits proof of a response, Claimant submits the following medical necessity argument. Medical Necessity The Supreme Court in the case of New Jersey Manufacturers Insurance Co. v. Hardy, 178 N.J. 327 (2004), held the No Fault Act is given liberal construction in favor of its intended remedial purpose of effecting broad protection for accident victims. Id at 329. The necessity of medical treatment is a matter to be decided, in the first instance, by the claimant’s treating physicians, and an objectively reasonable belief in the utility of a treatment or diagnostic method based on credible and reliable evidence of its medical value is enough to qualify the expense for PIP purposes. Thermographic Diagnostics v. Allstate, 125 N.J. 491, 512 (1991). On October x, 20xx, Mr. Smith sustained numerous injuries in a motor vehicle accident (see Exhibit C). Soon after, the patient sought chiropractic treatment with Dr. Who. On October x, 20xx, Mr. Smith came under the care of Dr. Who with complaints of bilateral radiating neck and back pain into the arms/legs among other abnormalities (see Exhibit D). Based on the examination and x-ray findings, Dr. Who prescribed a course in conservative chiropractic care. Dr. Who also referred the patient for MRI testing to better understand the nature of his injuries. On June x, 20xx, MRI testing of the cervical spine revealed disc herniation at the C3-C4 and C4-C5 levels, among other abnormalities (see Exhibit E). That same day, MRI testing of the lumbar spine revealed disc bulging at the L5-S1 level, among other abnormalities (see Exhibit E). On September x, 20xx, Mr. Smith came under the care of Dr. Feelgood who recommended continued chiropractic care and possible Manipulations Under Anesthesia procedures or “MUA” (see Exhibit F). On November x, 20xx, Dr. Who prescribed an electric moist hot pack (E0215) to help reduce myospasms throughout the spine (see Exhibit G, November x, 20xx physical exam report). That same day, Dr. Who requested a physical performance test be conducted to access the percentage of patient’s functional loss. On June x, 20xx, Dr. Who reported Mr. Smith returned for continued treatment after a
Forthright No.: 1xxxxxx July 11, 2015xx Page 11 of12 five-month absence (see Exhibit G, June x, 20xx physical exam report). On July x, 20xx, Dr. Who reported a plateau in benefit from conservative care as well as patient guarding and recommended MUA (see Exhibit G, July x, 20xx physical exam report). That same day, Dr. Who authored a report as to the need for the MUA procedures (see Exhibit H). On August x, 20xx, Dr. Who and Dr. Tylor performed a MUA of the neck, back, mid- back, shoulders, hips and pelvis to treat the patient’s painful symptoms (see Exhibit I, MUA operative reports). An August x, 20xx follow-up exam showed sufficient improvement to warrant a second MUA procedure (see Exhibit G, August x, 20xx physical exam report). That same day, Dr. Who recommended a 1-month home trial with a tens unit (E0730) to help the patient reduce medication usage and for pain control (see Exhibit G, August x, 20xx physical exam report). Dr. Who also prescribed a cervical traction pump (E0855) and a lumbar belt (L0976) to help decompress and stabilize the patient’s cervical and lumbar spine as well as to reduce myospasm and fibrosis (see Exhibit G, August x, 20xx physical exam report). On August x, 20xx, Dr. Who and Dr. Tylor performed a second MUA of the neck, back, mid-back, shoulder, hips and pelvis (see Exhibit I, MUA operative reports). An August x, 20xx follow-up exam showed sufficient improvement to warrant a third procedure (see Exhibit G, August x, 20xx physical exam report). On August x, 20xx, a third and final MUA was performed (see Exhibit I, MUA operative reports). On September x, 20xx, Dr. Who reported steady favorable progress and stated he expected to discharge patient within approximately four (4) weeks (see Exhibit G, September x, 20xx physical exam report). Dr. Who requested a physical performance test. The physical performance testing further demonstrates the MUA was very beneficial. Prior to the MUA on January x, 20xx, physical performance testing revealed the patient was at 49% whole person impairment (see Exhibit J, January x, 20xx physical performance test results). By September x, 20xx, Mr. Smith was at 30% whole body impairment and had improved to permit discharge by mid-November (see Exhibit J, September x, 20xx physical performance test results). From July x, 20xx to November x, 20xx range of motion testing of Mr. Smith showed great improvement (see Exhibit K). On November x, 20xx, Dr. Who deemed Mr. Smith to be at maximum medical improvement and was discharged (see Exhibit G, November x, 20xx physical exam report). Dr. Who authored a final report on November x, 20xx as to the injuries Mr. Smith sustained and the treatment he performed to return his patient to MMI (see Exhibit L).
Forthright No.: 1xxxxxx July 11, 2015xx Page 12 of12 The daily treatment notes demonstrate the patient went from a “9 out of 10” on the pain scale to a “4 out of 10”. The daily treatment records are extremely voluminous and Claimant will upload them separately on the Forthright website as “Exhibit M” to substantiate the claim. These records were forwarded to the Respondent in the form of pre-certification requests and available to Respondent on the Forthright website. However upon request of the Respondent, Claimant will forward a copy of the daily treatment records & notes. As such, it is respectfully submitted that an Award be entered in the amount of $27,735.58, with interest to be calculated by Respondent, together with attorney’s fees and costs. Very truly yours, PERSONAL INJURY LAW FIRM. By: ________________________________ C. KEVIN GRIM, JR. CKG/se cc: Respondent’s Attorney

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PIP Arb Example

  • 1. January x, 20xx Via Website Upload Justice 000 Summerville Avenue, Suite 000 Westfield, NJ 00000 Attn: Robert Stark Re: Chiropractic Center a/s/o John Smith v. Big Insurance Group Forthright File No.: xxxxxxxxxxxxxx Insurance Claim No.: xxxxxxxxxxxxxxxxxx Respondent File No.: xxxxxxxx Our File No.: xxxx D/A: xx/xx/xx Dear Mr. Stark: Please accept this letter in lieu of a more formal brief on behalf of the Claimant as our pre-hearing submission. The following demand balance, as per fee schedule, is due upon determination of failure to notice of EUO, failure to notice of IME, 72-hour rule, improper application of pre- certification penalty, medical necessity and under/nonpayment: DOS CPT/Procedures Amount Billed Amount Paid Amount Owed 10/19/11 99204 – Initial Exam $153.97 $0.00 $153.97 10/19/11 E1399 – Cervical Pillow $35.00 $0.00 $35.00 10/19/11 99070 – Pain Gel $30.00 $0.00 $30.00 10/19/11 E0230 – Ice Pack $25.00 $0.00 $7.88 10/19/11 97124, 97012, 97032 $80.28 $0.00 $80.28 10/21/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 10/24/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 10/26/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00
  • 2. Forthright No.: 1477174 July 11, 2015 Page 2 of12 10/28/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 10/31/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/02/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/04/11 72052 – X-Ray $127.81 $0.00 $127.81 11/04/11 72070 – X-Ray $80.87 $0.00 $80.87 11/04/11 72110 – X-Ray $111.08 $0.00 $111.08 11/04/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/07/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/09/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/11/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/14/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/16/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/18/11 99213 - 25 Office Exam $59.87 $0.00 $59.87 11/18/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/21/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/23/11 E0215 – Electric Heat Pad $60.21 $0.00 $60.21 11/23/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/25/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/28/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 11/30/11 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 12/02/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/05/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/07/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/09/11 99213 - 25 Office Exam $59.87 $0.00 $59.87 12/09/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/12/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/14/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/16/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/19/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/21/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/23/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/26/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/28/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 12/30/11 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/02/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/04/12 97750 59 - 16 Units $808.96 $0.00 $808.96 01/04/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/06/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 01/09/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 01/09/12 98941, 97124, 97012, 97032, 98943 $168.49 $0.00 $99.00 06/13/12 99213 - 25 Office Exam $59.87 $0.00 $59.87
  • 3. Forthright No.: 1477174 July 11, 2015 Page 3 of12 06/13/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/15/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/18/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/20/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/22/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/25/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/27/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 06/29/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/02/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 07/02/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/06/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/09/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/11/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/13/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/16/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/18/12 95831 - 4 Units $170.88 $0.00 $170.88 07/18/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/20/12 95851 - 4 Units $138.36 $0.00 $138.36 07/20/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/23/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/25/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/27/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 07/30/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/01/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/03/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 First MUA Procedure 08/03/12 22505 MUA - Spine $3,600.00 $0.00 $197.57 08/03/12 23700 50 MUA - LT Shoulder $1,200.00 $0.00 $327.09 08/03/12 23700 50 MUA - RT Shoulder $1,200.00 $0.00 $163.55 08/03/12 27275 50 MUA - LT Hip $1,200.00 $0.00 $304.43 08/03/12 27275 50 MUA - RT Hip $1,200.00 $0.00 $152.22 08/03/12 27194 50 MUA - Pelvis $2,400.00 $0.00 $2,400.00 First MUA Procedure, 20% due for Assistant 08/03/12 22505 - 62 MUA - Spine $720.00 $0.00 $39.51 08/03/12 23700 - 62 LT Shoulder $240.00 $0.00 $65.42 08/03/12 23700 - 62 RT Shoulder $240.00 $0.00 $32.71 08/03/12 27275 - 62 LT Hip $240.00 $0.00 $60.89
  • 4. Forthright No.: 1477174 July 11, 2015 Page 4 of12 08/03/12 27275 - 62 RT Hip $240.00 $0.00 $30.45 08/03/12 27194 - 62 50 Pelvis $480.00 $0.00 $480.00 08/06/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 08/06/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/08/12 95831 - 4 Units $170.88 $0.00 $170.88 08/08/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 Second MUA Procedure 08/10/12 22505 MUA - Spine $3,600.00 $0.00 $197.57 08/10/12 23700 50 MUA - LT Shoulder $1,200.00 $0.00 $327.09 08/10/12 23700 50 MUA - RT Shoulder $1,200.00 $0.00 $163.55 08/10/12 27275 50 MUA - LT Hip $1,200.00 $0.00 $304.43 08/10/12 27275 50 MUA - RT Hip $1,200.00 $0.00 $152.22 08/10/12 27194 50 MUA - Pelvis $2,400.00 $0.00 $2,400.00 Second MUA Procedure, 20% due for Assistant 08/10/12 22505 - 62 MUA - Spine $720.00 $0.00 $39.51 08/10/12 23700 - 62 LT Shoulder $240.00 $0.00 $65.42 08/10/12 23700 - 62 RT Shoulder $240.00 $0.00 $32.71 08/10/12 27275 - 62 LT Hip $240.00 $0.00 $60.89 08/10/12 27275 - 62 RT Hip $240.00 $0.00 $30.45 08/10/12 27194 - 62 50 Pelvis $480.00 $0.00 $480.00 08/10/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 08/10/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/13/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/15/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 08/17/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 08/17/12 98941, 97124, 97012, 97032 $132.67 $0.00 $99.00 Third MUA Procedure 08/17/12 22505 MUA - Spine $3,600.00 $0.00 $197.57 08/17/12 23700 50 MUA - LT Shoulder $1,200.00 $0.00 $327.09 08/17/12 23700 50 MUA - RT Shoulder $1,200.00 $0.00 $163.55 08/17/12 27275 50 MUA - LT Hip $1,200.00 $0.00 $304.43 08/17/12 27275 50 MUA - RT Hip $1,200.00 $0.00 $152.22 08/17/12 27194 50 MUA - Pelvis $2,400.00 $0.00 $2,400.00
  • 5. Forthright No.: 1477174 July 11, 2015 Page 5 of12 Third MUA Procedure, 20% due for Assistant 08/17/12 22505 - 62 MUA - Spine $720.00 $0.00 $39.51 08/17/12 23700 - 62 LT Shoulder $240.00 $0.00 $65.42 08/17/12 23700 - 62 RT Shoulder $240.00 $0.00 $32.71 08/17/12 27275 - 62 LT Hip $240.00 $0.00 $60.89 08/17/12 27275 - 62 RT Hip $240.00 $0.00 $30.45 08/17/12 27194 - 62 50 Pelvis $480.00 $0.00 $480.00 08/20/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/22/12 L0976 – Lumbar Belt $120.96 $0.00 $120.96 08/22/12 E0855 – Cervical Pump $502.63 $0.00 $502.63 08/22/12 97535 – Home Instructions $37.85 $0.00 $37.85 08/22/12 E0730 – Tens Unit $400.00 $0.00 $400.00 08/22/12 97535 – Home Instructions $37.85 $0.00 $37.85 08/22/12 A4630 Battery – 6 $33.66 $0.00 $33.66 08/22/12 A4556 Electrodes Pair – 6 $179.40 $0.00 $179.40 08/22/12 A4557 Lead Wires - 2 $35.88 $0.00 $35.88 08/22/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/24/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/27/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/29/12 98941, 97110, 97530 $145.37 $0.00 $99.00 08/31/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/05/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/07/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/10/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/12/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 09/12/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/14/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/17/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/19/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/21/12 97750 59 - 16 Units $808.96 $0.00 $808.96 09/21/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/24/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/26/12 98941, 97110, 97530 $145.37 $0.00 $99.00 09/28/12 95831 - 4 Units $170.88 $0.00 $170.88 09/28/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/01/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/03/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/05/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/08/12 98941, 97110, 97530 $145.37 $0.00 $99.00
  • 6. Forthright No.: 1477174 July 11, 2015 Page 6 of12 10/10/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/12/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/15/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/17/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/19/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/22/12 99213 - 25 Office Exam $59.87 $0.00 $59.87 10/22/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/24/12 98941, 97110, 97530 $145.37 $0.00 $99.00 10/26/12 95831 - 4 Units $170.88 $0.00 $170.88 10/26/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/05/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/07/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/09/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/12/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/14/12 95851 - 4 Units $138.36 $0.00 $138.36 11/14/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/16/12 98941, 97110, 97530 $145.37 $0.00 $99.00 11/16/12 99213 - 25 Discharge $59.87 $0.00 $59.87 Total Due: $27,735.58 The Patient’s Failure to Attend the EUO does not Rise to the Level of Egregious as Respondent failed to properly notice the patient’s Attorney In regard to Examinations Under Oath (EUO), N.J.A.F.I.U.A. v. Jallah, 256 N.J. Super 134 (App. Div 1992) is a governing case on auto insurance policy cooperation. Jallah dealt with a dismissal of a claim as a result of a failure to cooperate by not attending a statement under oath. The court held that a dismissal of an otherwise deserving claim for failure to submit to discovery should be reserved for egregious breaches of an insured’s failure to cooperate. The court referred to a dismissal of benefits as a “draconian remedy” Id. at 142. It is well settled that the right to conduct an examination under oath (EUO) is not absolute and unfettered. At the very least, it is circumscribed by ordinary standards of reasonableness and fairness. Prudential Prop. & Cas. v. Nardone 332 N.J. Super 126 (Law Div 2000). Respondent claims Mr. John Smith missed two examinations under oath (EUOs) scheduled on January x, 20xx and March x, 20xx. However, the record demonstrates Respondent failed to notify Mr. Smith via his attorney, Rudy Baylor. In addition, it appears Respondent’s EUO scheduling letters were for a Paul Doe, who
  • 7. Forthright No.: 1477174 July 11, 2015 Page 7 of12 was represented by Mr. Vincent Gambini, Esq. (see Exhibit C from Respondent’s November x, 20xx submission). These letters do not mention John Smith. On January x, 20xx, Respondent sent one (1) EUO scheduling letter to an attorney by the name of Mr. Atticus Finch for John Smith (see Exhibit C from Respondent’s December x, 20xx submission). However, on November x, 20xx, Mr. Jake Brigance wrote a letter to Respondent, Big Insurance Group (BIG), notifying them that his office, Houseman & Baylor, was now representing Mr. Smith in regards to his October x, 20xx accident (see Exhibit A). According to Jallah, dismissal of benefits is a draconian remedy reserved for egregious breaches. The evidence presented does not rise to level of an “egregious breach” on behalf of the patient as Respondent failed to notice to Mr. Smith’s attorney Rudy Baylor for the EUO. Furthermore, Claimant asserts the mere basis that Mr. Smith was a passenger in a host vehicle is not sufficient to deny coverage. Respondent has not articulated any suspicion of fraud to justify an EUO. Respondent has also failed to identify any other PIP policy in which they felt Mr. Smith had coverage under. Respondent’s actions were unreasonable and PIP benefits should not be denied for the improper notice of the EUO. Respondent’s Failure to Notice the Treating Provider of the IME violates N.J.A.C. 11:3- 4.7(e)(1) & (7) In regard to the Independent Medical Examination (IME) request, applicable case law has included IME as “discovery” under Jallah. Respondent claims Mr. John Smith missed two unexcused independent medical exams (IMEs) appointments scheduled on December x, 20xx and December x, 20xx. Once again, the IME scheduling notices were sent to the wrong attorney, Atticus Finch (see Respondent’s December x, 20xx submission, IME scheduling letters). It also appears Chiropractic Center was not noticed on any of the IME scheduling letters either. In accordance with N.J.A.C. 11:3-4.7(e)(1) which reads, in pertinent part, as follows: “The insurer shall notify the injured person or his or her designee that a physical examination is required to determine the medical necessity of further treatment, diagnostic tests or durable medical equipment. An insurer shall include reasonable procedures for the notification of the injured person and the treating medical provider where reimbursement of the further
  • 8. Forthright No.: 1477174 July 11, 2015 Page 8 of12 treatment, diagnostic testing or durable medical equipment will be denied for failure to appear at scheduled medical examinations.” Additionally, N.J.A.C. 11:3-4.7(e)(7) reads, in pertinent part, as follows: “Insurers may include in their decision point review plan a procedure for the denial or reimbursement for treatment, diagnostic testing or durable medical equipment after repeated unexcused failure to attend a scheduled physical examination. The procedure shall provide for adequate notification of the insured and the treating provider of the consequences of failure to attend the examination.” Claimant asserts the scheduling of the IME’s without notice to the patient’s attorney or Chiropractic Center violates the dictates of N.J.A.C. 11:3-4.7(e)(1) and (7). All IME correspondence post-dates the November x, 20xx letter of representation from the office of Houseman & Baylor (see Exhibit A). Failure to Attend the IME only bars payment of future treatment Nevertheless, should the DRP find the IME was properly noticed, Claimant asserts Respondent’s DPR Plan only allows for future medical expense benefits to be denied. Respondent’s Decision Point Review states “If there is more than one unexcused failures to attend the scheduled exam, notification will be immediately sent…The notification will place the parties on notice that all future treatment…will not be reimbursable as a consequence of failing to comply with the plan” (emphasis added) (see Exhibit D of Respondent’s December 5, 2013 submission). It does not appear Respondent ever sent proper notice to the medical provider that PIP benefits would be terminated for failure to attend the IME. Claimant respectfully requests the DRP award PIP benefits based on Respondent’s violation of N.J.A.C. 11:3-4.7(e)(1) and (7). Pre-certification Compliance N.J.A.C. 11:3-4.4(e) states in part, “Failure to request decision point review or pre-certification where required or failure to provide clinically supported findings that support the treatment…shall result in an additional co-payment not to exceed 50 percent…” Respondent alleges that Claimant Provider only made two (2) pre-certification requests for the entire course of chiropractic treatment; those being for DOS October x, 20xx to December x, 20xx and January x, 20xx to February x, 20xx. Respondent is incorrect.
  • 9. Forthright No.: 1xxxxxx July 11, 2015xx Page 9 of12 Claimant submits proof of pre-certification from October x, 20xx to December x, 20xx, from January x, 20xx to February x, 20xx, and from June x, 20xx to October x, 20xx (see Exhibit B), therefore, the 50% per-certification penalty applied by Respondent is improper. Substantial Compliance with Pre-certification Claimant asserts substantial compliance for the dates of service October x, 20xx to December x, 20xx (see Exhibit B). Provider Chiropractic Center (CC) requested the same or similar codes several times throughout the course of treatment and Respondent had knowledge of the several dates the codes were requested and made partial payment. Respondent now attempts to benefit from a technicality by applying the pre-certification penalty to codes that fell a few days outside the requested date range. The pre-certification penalty is supposed to be applied only when a provided treatment was neither requested nor supported with documentation, not to punish patients and providers based upon a technicality. Therefore, the 50% penalty was not proper. Claimant asserts the evidence supports sufficient to compliance with N.J.A.C. 11:3-4.4 and N.J.A.C. 11:3-4.7. As Respondent claims they did not receive the pre-certification request and Claimant has supplied proof (see Exhibit B), Claimant must present the following 72-hour rule violation claim. 72 Hour rule violation In Coalition for Qaulity Health Care v. NJ DOBI, 348 NJ Super 272, 306 to 308 (App. Div. 2002), the Court held that, for care path injuries, if the carrier does not respond to a Decision Point Review notice within the prescribed time period (3 business days), the treatment/testing may continue and is deemed approved. N.J.A.C. 11:3-4.7(c)(4) requires a response to either a Decision Point Review or pre-certification notice within 3 business days. Furthermore, N.J.A.C. 11:3-4.7(g) confirms that the failure of a carrier to respond to such notice is considered approval for the requested services. Claimant asserts a delayed response to the treatment was provided by Respondent in violation of the 72 Hour Rule. Claimant submitted pre-certification requests dated from October x, 20xx to December x, 20xx, from January x, 20xx to February x, 20xx, and from June x, 20xx to October x, 20xx (see Exhibit B).
  • 10. Forthright No.: 1xxxxxx July 11, 2015xx Page 10 of12 It appears Respondent has not submitted any proof that they responded in a timely fashion. Claimant asserts Respondent is barred from arguing medical necessity as they violated N.J.A.C. 11:3. In the instance, Respondent submits proof of a response, Claimant submits the following medical necessity argument. Medical Necessity The Supreme Court in the case of New Jersey Manufacturers Insurance Co. v. Hardy, 178 N.J. 327 (2004), held the No Fault Act is given liberal construction in favor of its intended remedial purpose of effecting broad protection for accident victims. Id at 329. The necessity of medical treatment is a matter to be decided, in the first instance, by the claimant’s treating physicians, and an objectively reasonable belief in the utility of a treatment or diagnostic method based on credible and reliable evidence of its medical value is enough to qualify the expense for PIP purposes. Thermographic Diagnostics v. Allstate, 125 N.J. 491, 512 (1991). On October x, 20xx, Mr. Smith sustained numerous injuries in a motor vehicle accident (see Exhibit C). Soon after, the patient sought chiropractic treatment with Dr. Who. On October x, 20xx, Mr. Smith came under the care of Dr. Who with complaints of bilateral radiating neck and back pain into the arms/legs among other abnormalities (see Exhibit D). Based on the examination and x-ray findings, Dr. Who prescribed a course in conservative chiropractic care. Dr. Who also referred the patient for MRI testing to better understand the nature of his injuries. On June x, 20xx, MRI testing of the cervical spine revealed disc herniation at the C3-C4 and C4-C5 levels, among other abnormalities (see Exhibit E). That same day, MRI testing of the lumbar spine revealed disc bulging at the L5-S1 level, among other abnormalities (see Exhibit E). On September x, 20xx, Mr. Smith came under the care of Dr. Feelgood who recommended continued chiropractic care and possible Manipulations Under Anesthesia procedures or “MUA” (see Exhibit F). On November x, 20xx, Dr. Who prescribed an electric moist hot pack (E0215) to help reduce myospasms throughout the spine (see Exhibit G, November x, 20xx physical exam report). That same day, Dr. Who requested a physical performance test be conducted to access the percentage of patient’s functional loss. On June x, 20xx, Dr. Who reported Mr. Smith returned for continued treatment after a
  • 11. Forthright No.: 1xxxxxx July 11, 2015xx Page 11 of12 five-month absence (see Exhibit G, June x, 20xx physical exam report). On July x, 20xx, Dr. Who reported a plateau in benefit from conservative care as well as patient guarding and recommended MUA (see Exhibit G, July x, 20xx physical exam report). That same day, Dr. Who authored a report as to the need for the MUA procedures (see Exhibit H). On August x, 20xx, Dr. Who and Dr. Tylor performed a MUA of the neck, back, mid- back, shoulders, hips and pelvis to treat the patient’s painful symptoms (see Exhibit I, MUA operative reports). An August x, 20xx follow-up exam showed sufficient improvement to warrant a second MUA procedure (see Exhibit G, August x, 20xx physical exam report). That same day, Dr. Who recommended a 1-month home trial with a tens unit (E0730) to help the patient reduce medication usage and for pain control (see Exhibit G, August x, 20xx physical exam report). Dr. Who also prescribed a cervical traction pump (E0855) and a lumbar belt (L0976) to help decompress and stabilize the patient’s cervical and lumbar spine as well as to reduce myospasm and fibrosis (see Exhibit G, August x, 20xx physical exam report). On August x, 20xx, Dr. Who and Dr. Tylor performed a second MUA of the neck, back, mid-back, shoulder, hips and pelvis (see Exhibit I, MUA operative reports). An August x, 20xx follow-up exam showed sufficient improvement to warrant a third procedure (see Exhibit G, August x, 20xx physical exam report). On August x, 20xx, a third and final MUA was performed (see Exhibit I, MUA operative reports). On September x, 20xx, Dr. Who reported steady favorable progress and stated he expected to discharge patient within approximately four (4) weeks (see Exhibit G, September x, 20xx physical exam report). Dr. Who requested a physical performance test. The physical performance testing further demonstrates the MUA was very beneficial. Prior to the MUA on January x, 20xx, physical performance testing revealed the patient was at 49% whole person impairment (see Exhibit J, January x, 20xx physical performance test results). By September x, 20xx, Mr. Smith was at 30% whole body impairment and had improved to permit discharge by mid-November (see Exhibit J, September x, 20xx physical performance test results). From July x, 20xx to November x, 20xx range of motion testing of Mr. Smith showed great improvement (see Exhibit K). On November x, 20xx, Dr. Who deemed Mr. Smith to be at maximum medical improvement and was discharged (see Exhibit G, November x, 20xx physical exam report). Dr. Who authored a final report on November x, 20xx as to the injuries Mr. Smith sustained and the treatment he performed to return his patient to MMI (see Exhibit L).
  • 12. Forthright No.: 1xxxxxx July 11, 2015xx Page 12 of12 The daily treatment notes demonstrate the patient went from a “9 out of 10” on the pain scale to a “4 out of 10”. The daily treatment records are extremely voluminous and Claimant will upload them separately on the Forthright website as “Exhibit M” to substantiate the claim. These records were forwarded to the Respondent in the form of pre-certification requests and available to Respondent on the Forthright website. However upon request of the Respondent, Claimant will forward a copy of the daily treatment records & notes. As such, it is respectfully submitted that an Award be entered in the amount of $27,735.58, with interest to be calculated by Respondent, together with attorney’s fees and costs. Very truly yours, PERSONAL INJURY LAW FIRM. By: ________________________________ C. KEVIN GRIM, JR. CKG/se cc: Respondent’s Attorney