New regulations for motor vehicle accident (MVA) claims, also known as Personal Injury Protection (PIP) claims, went into effect January 4, 2013. These regulations created for the first time a hospital fee schedule, the Hospital Outpatient Surgery Fee Schedule (HOSF). This fee schedule addresses specifically outpatient surgeries conducted at New Jersey hospitals. It does not govern charges associated with inpatient services; and emergency room (ER) surgical services were specifically exempted from application of the fee schedule. Both inpatient and ER services are to be paid by PIP insurance carriers at the usual and customary rates (UCR) of the hospital. Not surprisingly, PIP carriers in the context of ER services have been attempting to pay less than a hospital’s UCR through a variety of ways.
- The ER Modifier. The new regulations refer to use of an “ER” modifier to indicate that the hospital services were rendered as part of hospital emergency room treatment. It is best to use the ER modifier, as called for in the regulations, so as to deny PIP carriers the ability to argue against the applicability of UCR. However, it is our position that use of the modifier is not a prerequisite to being paid at the hospital’s UCR. The provision calling for use of the modifier, we contend, refers only to outpatient surgery services conducted pursuant to ER treatment. Also, we contend, the bill (UB) itself, including the words “Emergency Room” appearing next to the ER evaluation code 9928X, is quite clear in these circumstances that the services are ER services. In our view, use of the modifier is aimed at informing the carrier as to the nature of the services, and the UB achieves that with or without the modifier.
- Multiple Modality Reduction (MMR) Formula Applied to Radiology. Carriers have attempted to apply MMR to ER radiology. MMR is the formula applied to surgeries whereby the first surgical procedure is paid at 100%, and any additional procedures performed on the same day are paid at 50%. Carriers have tried to apply this to ER radiology. We have been aggressively opposing this practice and continue to do so.
- Applying the Physician Fee Schedule to ER Radiology. Carriers have also been trying to apply the physicians’ fee schedule rates to ER radiological services. This would result in the hospital often being paid even less than the hospital outpatient surgery fee schedule rate. There is scant support for this practice on the part of carriers, but that has not deterred them. We have also been aggressively opposing this practice.
If you are a New Jersey hospital, there is little doubt that your facility is experiencing the above underpayments. As a general proposition, you should be reimbursed at your billed charges for the ER services you render to patients suffering as a result of a motor vehicle accident. Assuming your charges are your usual and customary rates, and they are reasonable for the geographic area in which your facility is located, PIP carriers should be paying you at your billed charges for ER services. Anything short of this is likely to be a claim that should be arbitrated.
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