New Evidence for Medical Provider Claims

April 23, 2018

Medical provider claims in New Jersey are becoming increasingly prevalent.  The majority of these claims allege that the provider was entitled to additional compensation for the treatment at issue.  These providers dispute the explanation of benefits provided by the carrier’s bill review company. 


Up until recently, providers’ attorneys have been submitting “cherry-picked” billing proofs from the same provider or other providers in the area to show their entitlement to additional compensation for the treatment at issue.  The problem with these billing proofs is the providers and their firms are able to pick and choose the billing proofs they submit. This means they can pick only those bills which support their entitlement to additional compensation while potentially ignoring a voluminous amount of other bills which discredit their argument. A recent unreported Appellate Decision helps to remedy this problem and level the playing field for respondents. 


The Appellate Division issued an unreported decision in 2017 addressing other evidentiary standards upon which to evaluate these cases in University Physicians Associates v. Transport Drivers, Inc. While the case is not of precedential value, the opinions reached by the Appellate Division affirming the Judge of Compensation’s Decision are both instructive for the proper evidence for resolving these claims.


The Appellate Court held national databases of fees such as those published by Ingenix, Fair Health, and Wasserman, are evidence of the reasonableness of fees.  The Appellate Court held the Judge appropriately relied upon the national database as well as the use of paid fees rather than billed fees to represent a more accurate measure of “reasonable and prevailing fees.”


This is the most instructive Decision issued to date from the Appellate Court as to how these claims will be resolved in the future. In my experience arguing this issue, Judges of Compensation have reported their intent to rely on this case and the underlying Judge of Compensation’s Decision in their decisions going forward.


Bill review companies should utilize this Appellate decision when reviewing bills since the court specifically cites to the use of the 75th percentile from national databases for valuing the treatment. 

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