b'CODING Update ComplianceLEGAL NUTRITIONCouncilANJC Leadership LEGAL EASE NUTRITION REHAB Council Executive Directors Update LEGAL Q&A CHIROASSISTINSURANCE Update INSURANCE Update Legislative UpdateBy Matt MinnellaANJC Director of Insurance & Regulatory Affairs TECHNIQUE CouncilFall Insurance UpdateNew PIP Billing Requirements: New Jersey has passed state MedicareQ&AMedicare Updatelaws mandating that bills for personal injury protection (PIP)OUR HEALTHclaims and Workers Compensation claims must be billed electronically. A provider may be exempt from this requirement if they bill less than 25 of these types of claims per month. This is 25 claims total, not per carrier. The New Jersey Department of Banking and Insurance (DOBI) advised that the exception would be based on an average of claims per month. If the 25 was exceeded one month it doesnt mean they have to submit electronically if they still average below the 25. This requirement for PIP claims went into effect on September 1, 2019. This requirement for Workers Compensation claimsplans also known as Medigap plans. These plans are supposed will go into effect on November 1, 2019. to only pay for the patient cost-sharing (co-pay, coinsurance, Many members received letters from PIP carriers and/ordeductible) for Medicare-allowed services. For chiropractors, pre-certification vendors such as Geico, Auto Injury Solutionsonly spinal manipulations (98940-98942) are Medicare-allowed and Prizm stating that claims must include supportingservices. For several years Horizon has been paying all services documents (treatment notes) in order to be considered abilled on these claims when the plans were not supposed to clean claim, accepted and paid. The statute does not mentioncover these services. the requirement for notes to be submitted or receivedTechnically, legally, a carrier can recoup payments made in electronically for PIP bills and there are no regulations writtenerror for up to 18 months. This is 18 months from the date of for this statute yet. However, many carriers require notes topayment, NOT date of service. However, there is New Jersey be submitted with bills per their Decision Point Review (DPR)case law that may negate this in certain cases. plans which are reviewed and approved by the NJ DOBI. A potential issue is that not all clearinghouses have theWe are recommending two possible courses of action to capability to submit treatment notes electronically. It appears,members: if providers and/or their clearinghouses cannot submit the1Most major malpractice insurance policies include a rider notes electronically, many PIP carriers intend to deny claims asincluded automatically and for no additional charge that of September 1.covers a certain amount of money to pay for an attorney to We are seeking clarity from NJ DOBI on two questions: defend recoupment attempts from carriers. In most cases these riders are for recoupments resulting from an audit 1 Are the carriers allowed to require the notes be sentrather than a carrier billing error. However, we have seen electronically along with the bills? If so, what formats mustmembers assigned an attorney for this issue and we have the notes be submitted in? seen recoupments ceased on similar situations in the past. 2How do providers who bill less than 25 PIP claims per monthWe cannot guarantee the members malpractice will apply make carriers aware of this so that their paper claims are stillthis coverage and assign an attorney or that the attorneyaccepted? Is there a standardized notification that carrierswill be able to stop the recoupments, but we do believemust accept to allow for paper bills?this is the best initial line of defense. Our general counsel has sent a letter to NJ DOBI asking for2If the members malpractice carrier will not assign an clarification on these questions and our lobbyist is also seekingattorney or their policy does not have this coverage, we answers to these questions from the state. As soon as we haverecommend they appeal the decision with the carrier additional information, we will advise membership. In the(instructions should be included in the notice letter) and file meantime, we recommend members who treat PIP patientsa complaint with NJ DOBI. Instructions, links, sample forms inquire with their clearinghouse if they are aware of thisand a brief webinar on filing DOBI complaints can be found situation and if they are able to comply with the new law andon our website under the Insurance tab then Appeal & requirements. If your office does bill fewer than 25 PIP claimsForms then under Complaints on that page. per month, we recommend sending your paper claims with aData iSight: For nearly two years we have seen a large cover sheet explaining this and advising that the paper claimsnumber of out-of-network providers having their claims should still be accepted until a formal notification method isreduced by Data iSight on claims from various insurers, but provided by the state.primarily CIGNA and Aetna. Data iSight, which is a subsidiary Horizon Medigap Recoupments: Many members areof Multiplan, is routinely reducing reimbursements for out-of-experiencing recoupments on Horizon Medicare supplementalnetwork providers without having any contract or other written 12 I Fall 2019 www.anjc.info'