In an effort to combat tens of millions of dollars of fraud and abuse in the state's auto insurance system, AICRA required the New Jersey Department of Banking & Insurance to establish guidelines for the standard treatment of injuries sustained in automobile accidents.

After months of research and dialogue with state boards that license various medical professionals, the Department approved a set of medical treatment guidelines and a list of valid diagnostic tests. The new rules ensure that injured auto accident victims receive prompt medical treatment from responsible medical professionals while adding reasonable controls to prevent widespread fraud and abuse.

AICRA required the New Jersey Department of Banking & Insurance to establish guidelines for the standard treatment of certain injuries sustained in automobile accidents.

After months of research and dialogue with the state's various medical licensing boards, the Department approved a set of medical treatment guidelines or Care Paths and a list of valid diagnostic tests as the standard course of treatment for soft tissue injuries of the neck and back resulting from automobile accidents. Care Paths provide that treatment be evaluated at certain intervals called Decision Points. Treatments that vary from the prescribed Care Paths will be reimbursable only when warranted by reason of medical necessity.

A copy of the Care Paths is available on the Department's web site at http://www.njdobi.org .

It is important to note, however, that the medical treatment guidelines do not apply to treatment administered during emergency care or within the first ten days after the accident causing the injury.

The Care Paths discussed above provide that treatment be evaluated at certain intervals called Decision Points. At such decision points the treating medical professional must communicate information about further treatment and/or services they intend to prescribe for the injured individual to the automobile insurance company. This allows both the treating medical provider and the automobile insurance company an opportunity to periodically review the course of treatment and discuss if it is the most appropriate level of care.

If the treating medical provider fails to submit requests for decision-point reviews, payment of bills may be subject to penalty co-payments even if services are determined to be medically necessary. Additionally, insurers have three business days to respond to a physician's decision point review request. If a response is not given within that time, a medical provider has the right to continue treatment as planned.

Any denial of reimbursement for further treatment or tests by an insurer must be made by a physician. If a decision is made not to provide further benefits, the patient may either discontinue treatment, appeal the decision to the company's internal appeals process or contest the decision through a dispute resolution process (see PIP Dispute Resolution System).

Decision-point requirements do not apply during emergency care preformed in a hospital emergency room or within the first 10 days of the insured accident.

AICRA provides that insurers may require pre-certification of certain treatments or diagnostic tests for injuries not included in the Medical Care Paths. Under pre-certification, treatment plans are reviewed and assessed to ensure that injured persons are receiving the appropriate level of medically necessary care for their injuries.

Pre-certification does not apply to treatment or diagnostic tests administered during emergency care preformed in a hospital emergency room or during the first 10 days after the accident causing the injury. All treatment within the first 10 days after the accident causing the injury, however, must be medically necessary to be reimbursable.

Pre-certification does not require prior authorization for each and every treatment in the course of providing medically necessary care. Certain treatments and diagnostic tests however, require pre-certification. The following list provides examples of the types of treatment and testing which may be required to be pre-certified by individual automobile insurance companies:

• Non-emergency hospital stays
• Non-emergency surgical procedures
• Specified services provided by physical therapists
• Specified services provided by chiropractors
• Durable medical equipment
• Home health care
• Hospice care
• Infusion therapy
• Prosthetic devices
• Prescription drugs

Each company has detailed information on how a treating physician should make pre-certification requests.

If the pre-certification requirements in the policy covering an injured person are not met, expenses for medically necessary treatment and testing are subject to additional co-payment penalties of up to 50 percent.

Pre-certification does not mandate the use of certain health care providers or facilities. However, pre-certification plans do include provisions that durable medical equipment, diagnostic tests and prescription drug be obtained directly from a licensed and certified supplier designated by the insurer to avoid co-pay deductibles (see Voluntary Networks).

Under AICRA, certain diagnostic tests are no longer reimbursable under PIP as they have been determined by state regulators and the various licensing boards to have no significant value in the evaluation and treatment of injuries sustained in automobile accidents. Insurers are no longer permitted to pay for:

• Spinal diagnostic ultrasound
• Iridology
• Reflexology
• Surrogate arm mentoring
• Surface electromyography
• Mandibular tracking and stimulation

Personal injury protection medical expense coverage also does not provide reimbursement for certain diagnostic tests which have been identified by the New Jersey State Board of Dentistry as failing to yield data of sufficient volume to alter or influence the diagnosis or treatment plan employed to treat TMJ/D.

PIP medical expense benefit coverage will provide for reimbursement of certain diagnostic tests, which have been determined to have value in the evaluation of injuries, the diagnosis and development of a treatment plan for personal injuries in a covered accident.

Prior to the reform law, disputes over excessive medical treatment were resolved by panels of lawyers - not doctors - and a typical claim could take 12 to 18 months to be processed. Under the new arbitration system, new procedures have been established and implemented for the resolution of disputes concerning the payment of medical expenses and other benefits provided under a patient's PIP coverage.

Under the new dispute resolution system, full-time professional arbitrators review and render decisions concerning disputes regarding PIP medical benefits. All decisions rendered are in writing and are binding.

Disputes regarding medical expense benefits may include, but are not limited to:

• Matters concerning interpretation of the PIP provisions
• Whether the treatment is in accordance with the provisions of applicable statutes and rules or the terms of the policy
• The eligibility of treatment for compensation or reimbursement
• The eligibility of the provider to be compensated or reimbursed under the terms of the policy or the provisions
• Whether the treatment was actually performed
• Whether the diagnostic tests performed are recognized ones
• The necessity and appropriateness of consultation with other health care providers
• Disputes regarding the auto insurance medical fee schedule
• Whether the treatment is reasonable, necessary and in accordance with the medical protocols.

If there is a dispute regarding Personal Injury Protection coverage, any party involved may request a resolution of the dispute. The request for dispute resolution must be made in writing to the designated dispute resolution organization and copies sent to the other parties. Once the dispute resolution organization receives the request, the matter will be assigned to dispute resolution professional.

Either party involved in an arbitration proceeding concerning PIP benefits can seek to have the matter reviewed by a Medical Review Organization (MRO). These independent medical review organizations are reviewed and certified by the Department of Banking & Insurance and must be capable of performing reviews for all primary specialties and disciplines.

In addition, the MRO must utilize health care professionals in the same disciplines as the treating provider, be licensed in New Jersey, actively practicing and be board certified in their specialty.

Any party filing the appropriate information and paying the required administrative fee may initiate arbitration. The American Arbitration Association administers the PIP Dispute Resolution System and they can be reached at (732) 560-9560. The Rules for the Arbitration of No-Fault Disputes in the State of New Jersey can be found on the A.A.A.'s Web site at http://www.adr.org .

Most automobile insurance companies will encourage policyholders to obtain certain services and/or supplies from a voluntary network vendor for certain durable medical equipment, diagnostic testing and prescription drugs. If your patient selects a vendor from the voluntary network, their co-payment for that service will be reduced in full or in part. Use of these networks in strictly voluntary.

AICRA encouraged automobile insurance companies to offer various deductible and co-payment plans within their PIP medical benefits coverage. PIP patients are still responsible for the regular $250 deductible and 20 percent co-payment on medical expense benefits between $250 and $5,000 on either the basic or standard policy. Insurers are also required to offer policyholders the option of selecting a PIP deductible of $500, $1,000, $2,000 or $2,500.

Automobile insurers can require that the insured advise and inform them about their injury and claim in a timely manner. If such a request for information is disregarded, an additional co-payment of 25 percent may apply for information received 30 or more days after the accident or 50 percent when received 60 or more days after the accident.

Individual automobile insurance companies may also require co-payments for certain goods or services received during the course of treating accident-related injuries.

All deductibles and co-payments are on a per accident basis.

See Also:
Coverages and Policy Options
Other Aspects of AICRA