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Health provider group looks to delay new regulations on reimbursement limits

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A health care provider group is looking to repeat history by delaying in court the New Jersey Department of Banking and Insurance's new regulations to widen the net of medical procedures subject to reimbursement limits under personal-injury protection, or PIP, set to take effect Jan. 4.

As the New Jersey Association of Ambulatory Surgery Centers expected, DOBI denied its appeal for a stay of the new rules on Nov. 23. But when DOBI made the same move in 2007, adding more procedures to the physicians’ fee schedule in an effort to slow rising car insurance costs, those changes were delayed in court for two years before they took effect — and the NJAASC is confident the state Superior Court will issue a stay on the implementation of DOBI’s latest regulations, as well.

“Our real focus from the beginning was not on the amount of money we would be reimbursed, because no doctor is going to go out of business doing procedures under this new PIP fee schedule,” said Jeffrey Shanton, chair of the advocacy and legislative affairs committee of the NJAASC. “What really concerns us is DOBI has decided to not to equally pay ambulatory surgical centers for certain procedures and limit where certain procedures can be done. But whether doctors are performing procedures at an ambulatory center or a hospital, it’s going to be done.”

To establish the new physicians’ fee schedule — which restricts the types of procedures that will be reimbursed at ASCs, and sets hospital outpatient surgical facility fees 35 percent higher than ASC fees for the same medical services — DOBI used the Centers for Medicare and Medicaid Services’ 2011 Medicare Resource-Based Relative Value Scale.

But Shanton said people insured under Medicare are mostly part of an older population “that’s not going to need spinal fusions, so just because a procedure is not on the Medicare-approved list doesn’t mean it’s not safe for a doctor to do at a surgical center.”

New Jersey Manufacturers Insurance spokesman Eric Stenson previously told NJBIZ adding more procedures to the fee schedule “adds more predictability to the system … (and) with more procedures on the fee schedule, there would be fewer billing disputes, as well.”

Reforming the PIP arbitration system to control costs and council fees is a key part of the new regulations — and a move Stenson said “will ultimately benefit policy holders” — as DOBI reported attorneys’ fees were greater than the PIP benefits awarded in 31 percent of billing disputes that awarded those fees in 2010.

But Shanton said the insurance carriers “bring a lot of those costs on themselves,” as he noted many court disputes would be avoided if the companies “looked at doctors’ appeals on wrong payments and said, ‘I made a math error’ — but they don’t do it, so they force us to go the only route left, which is arbitration.”

“It doesn’t matter how little or how much you are owed. If an insurer paid it wrong, they paid it wrong, and doctors are entitled to what they were owed,” Shanton said. “Insurers think having limits on reimbursements will cut down on arbitration, because they assume no doctor is going to go through all the BS for $40. But if I sent my check to my auto insurer and it was $40 less than what was owed, they wouldn’t give me auto insurance — so why would a doctor let that go?”

The NJAASC has filed a request for a stay on DOBI’s adoption of the regulations with the appellate division of the New Jersey Superior Court. A court date is pending, but Shanton believes both sides will be in court before the rules are implemented Jan. 4.

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