Proposed NJ-PIP regulations in relation to physician reimbursements and patient care.

PROPOSED PIP REGULATIONS

Please submit your comments to the DOBI including detailed description explaining exactly how this may negatively affect your organization and the quality of care of your patients if this is your opinion.  The deadline to submit comments is 10/17/11.  Please submit your comment to the following contact information via email, facsimile, or regular mail to the following location:

Robert J. Melillo, Chief

Legislation and Regulation

New Jersey Department of Banking and Insurance

20 West State Street

PO Box 325

Trenton, NJ 08625-0325

Fax: (609) 292-0896

Email: legsregs@dobi.state.nj.us

 The following contains an overview of issues which demand our attention:

·         PIP Networks to utilize Workers’ Compensation Managed Care.  The presence of PIP networks encourages payers to create incentives for their insured to visit their “in-network” providers.  This will force patients out of your practice and into the “in-network” provider’s office.  One particularly disturbing incentive is that fact that payers will be permitted by law to waive the patient’s out of pocket co-pay and deductible expense’s when they go to “in-network” doctors.  As providers, this practice is strictly prohibited by law resulting possible insurance fraud charges. 

·         APPEALS PROCESS:  These proposed regulations only allow providers a 5 day window of time in which to appeal any medical necessity denial’s during your initial precertification of treatment.  If you do not respond with those 5 days, you will not be paid for those services unless you successfully attempt to re-precertify, appeal and arbitrate after the fact.  

·            Medicare CCI Edits May Cut Your Daily Reimbursement in Half.  To begin, Medicare’s Correct Coding Initiative was specifically designed to limit government expenditures on the program itself not to regulate for profit commercial interests.  The proposed regulations clearly define the Medicare Correct Coding Initiative (“CCI”) edits as an acceptable reimbursement for all NJ PIP claims.  CCI edits maintain a proven track record of bundling services, decreased allowable procedures, and lower reimbursements to providers leading to lower quality of patient care.  Providers working within the daily cap may not be able to reach the new increase as codes are bundled. For example, CPT codes 97124, 97112, 97124 may not be reimbursable with CPT codes 98940-98942..

·         Pain Management Services. This new proposal will reduce the reimbursement for most pain management procedures. Twenty-Seven codes/procedures that are represented on the new fee schedule appear without an ASC reimbursement amount. Therefore, proposing these procedures should be hospitals. These procedures include Discographies, Discectomies, and Decompressions, just to name a few.

·         Duty To Cooperate Extended to Doctors Under Assignment of Benefits.  The newly proposed regulations will require physicians to attend Examinations Under Oath and make available non-medical corporate and licensure documents.  Decreased available treatment time and increased “red tape” opposes the idea of a quick, cheap, and economically alternative to in court litigation. 

·         Paper Only Arbitration Hearings.  For fee scheduled claims less than $1,000 the proposed regulations allow for “on the paper” hearings only.  Meaning legal representation and doctor/patient testimony will not be present at hearings. This raises concerns that the on paper arbitrations may not represent a fair review of your claim.   

·          Kinesiotaping New regulations will not allow for separate reimbursements for kinesiotaping (similar to hot/cold packs) and the surgical strapping codes (i.e. CPT 29220). This will increase costs to the doctors and patients.  This may also deter some physicians from performing this service which will decrease the quality of care given to patients.

·          Implementation of a multiple procedure discount. Approximately 1,100 new CPT codes were added to the fee schedules, CPT codes that do not appear on the outpatient facility fee schedule are not eligible for reimbursement.

·         Recognition of FAIR HEALTH as a national UCR database.

The deadline to submit your comment of October 17, 2011 is fast approaching.  To date a vast majority of comments submitted have been supportive of the proposed changes.  If you believe that these changes will adversely affect your organization please notify NJ DOBI of your position.  Please forward this correspondence to any and all parties who may be affected by these changes.  

Keri Fessler

President

keri@epsnj.com

                              

O:  973-305-8830x108 | F: 973-305-8818 | C: 973-405-4429

                                       

                                                                                  www.epsnj.com