New Jersey Commercial Arbitrations
The New Jersey State Legislature enacted the out-of-network consumer protection act which takes effect on 9/1/18. The new law allows for arbitration. It is important that you know your rights and responsibilities under this new legislation, and how De Frank, McCluskey & Kopp is well positioned to assist in this ever-changing regulatory environment. The new law applies to the following services:
- Non-self-funded plans or self-funded plans that elect to be bound by arbitration.
- The services must be provided on emergency or urgent care.
In instances where medically necessary emergency or urgent care is provided, as defined by 42 U.S.C. s.1395dd et. seq., “Emergency Medical Treatment and Active Labor Act” AND the provider does not participate in the patient’s health insurance network, the following applies:
- Providers may not bill patients in excess of the patient’s deductible, co-pay or available co-insurance.
- Providers may bill the patient’s health insurance carrier for any outstanding expenses not covered by the patient’s co-pay, deductible or coinsurance.
- Providers do not need to obtain an assignment of benefits from the patient as benefits for medically necessary emergency or urgent care are automatically assigned.
- The insurance carrier must issue the check directly to the medical provider not the patient.
Based upon our years of experience with alternative dispute resolution and insurance claims for payment of medical treatment, it is recommended and suggested that you utilize the services of De Frank, McCluskey & Kopp to comply with the reimbursement dispute requirements outlined below:
- Providers must submit all bills to the patient’s health insurance carrier.
- The insurance carrier has 20 days from the date they receive the medical provider’s bill to pay the claim or notify the provider that they consider the bill to be excessive.
- If the carrier notifies the medical provider that they consider the bill to be excessive, the medical provider and the carrier have 30 days from the date of the carrier’s notification to negotiate a settlement.
- If there is no settlement reached after 30 days, the carrier shall pay the medical provider the insurance carrier’s final offer.
It is important to note that should the dispute proceed to arbitration, the arbitrator will only consider the final amounts requested by the two parties. Therefore, it is recommended that De Frank, McCluskey & Kopp handle the negotiations AND arbitrations to ensure maximum recovery and continuity between negotiation and arbitration.
- The arbitrator is required to choose between the medical provider’s final offer and the insurance carrier’s final offer for these reasons, it is to the medical provider’s advantage to have De Frank, McCluskey & Kopp negotiate the claim.
- The arbitration decision shall be entered within 45 days from the date in which the arbitration is filed. Each party is responsible for their own attorney’s fees and costs.
Please contact the undersigned directly so the correct documents are submitted to prevail at arbitration. I am available via email at email@example.com, or via telephone at 973-696-1900. De Frank, McCluskey & Kopp will help you navigate this new legislation.
De Frank, McCluskey & Kopp has decades of experience in dealing with insurance companies to ensure that our clients receive fair compensation for treatment rendered. In addition to the necessary experience, De Frank, McCluskey & Kopp has the resources to professionally and promptly handle these billing disputes to generate desired and profitable results. Further, we are available to answer clients’ questions and provide further assistance with compliance as required by the aforementioned statute.