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New Post has been published on http://seancallagyevents.com/2016/05/11/help-us-help-role-medical-documentation-new-jersey-pip/
Help Us Help You: The Role of Medical Documentation in New Jersey PIP
The Proof is in the Pudding. When a medical provider treats a patient for injuries caused by a motor vehicle accident, the medical documentation will often determine if reimbursement is required by the auto insurer. The provider has the burden to prove the treatment was medically necessary and reasonable. Miltner v. Safeco Ins. Co. of Am., 175 N.J. Super. 156 (Law Div. 1980). The provider must carry that burden by a preponderance of the evidence.
Pursuant to N.J.A.C. 11:3-4.2, “medically necessary” or “medical necessity” means that the medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person, and; (1) The treatment is the most appropriate level of service that is in accordance with the standards of good practice and standard professional treatment protocols including the Care Paths … as applicable; (2) The treatment of the injury is not primarily for the convenience of the injured person or provider; and (3) Does not include unnecessary testing and treatment.
Focus on the phrase “clinically supported.” This means the provider personally examined and evaluated the patient in making an assessment of the patient’s subjective and objective complaints, as well as considered prior test results and recorded all observations and findings.
It is imperative to recognize DOBI (the New Jersey Department of Insurance and Banking), the regulatory body for New Jersey PIP, has adopted Care Paths, which are “typical” courses of intervention in the treatment of a patient. DOBI recognizes the Care Paths may vary, depending on the medical needs of the patient. Deviations, however, must be properly documented to increase the likelihood of success at arbitration. For example, a patient may have co-morbidities or pre-existing conditions requiring more or different treatment that would otherwise be typically provided, but this must be explained in the documentation by the treating doctor.
For example, let’s say a “typical” course of treatment for someone injured in a motor vehicle accident is x weeks of conservative care, such as chiropractic care. If that patient has a co-morbidity that would require additional conservative care and the patient continues to improve with care, this additional care will generally be deemed medically necessary if the medical records support that position.
Similarly, let’s say the patient remains symptomatic after a “typical” period of conservative treatment, and the “typical” course of treatment at that stage would be surgical intervention. What if the patient does not want to undergo surgery at that time for reasons also explained in the medical record? That important information might provide a reasonable basis to continue with conservative care and/or injection treatment.
Check the Medical Denials. Auto insurers are required to have medical denials before they may properly deny treatment based on medical necessity. N.J.A.C. 11:3-4.7(c)4 provides, “All determinations on treatments or tests shall be based on medical necessity and shall not encourage over or underutilization of benefits. Denials of decision point review and precertification requests on the basis of medical necessity shall be the determination of a physician.”
Make sure medical denials address the requested treatment, and the insurer’s doctor is of the same specialty as the treating doctor.
Three day Rule. Auto insurers are required to respond to a provider’s pre-certification request in three business days. Check to see when the insurer responds to your request. (Make sure you can prove the day your request was sent, and that it was sent to the proper facsimile number, etc. of the insurer.) An untimely denial may be another way to show medical necessity of treatment.
In sum, the role of medical documentation in a New Jersey PIP arbitration is paramount. If the treating doctor documents all clinical findings made by thorough evaluation and examination, and then explains the medical basis for recommended treatment, our chances of success are increased significantly. As Jerry Maguire has so eloquently stated, help us help you.
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