The document discusses multiple workers' compensation cases and legal issues. It begins with a case where a lien claimant, Passages Malibu, sought reconsideration of a lower payment amount for services provided to an injured worker. It then discusses issues related to denied billing codes for psychological testing and services. Specifically, it provides context and documentation showing codes were authorized but later denied. The document ends with a discussion of denied surgical codes, with the insurer citing CCI edits and lack of proper modifiers as reasons for denial.
This newsletter provides updates on recent cases related to personal injury law. In Montgomery v Lanarkshire Health Board, the Supreme Court overturned previous rulings and found that patients should be made aware of any material medical risks or alternative treatments. In road traffic cases, a recent EU court ruling found that insurance must cover any vehicle use consistent with its normal function, placing more claims under the MIB agreement. Two psychiatric injury cases reaffirmed that employers are not responsible for stress claims without notice of particular vulnerabilities and damages for shock require witnessing a horrifying event directly.
This document provides a summary of recent developments in personal injury law from November 2015. It discusses cases related to causation of loss, withdrawal of admission, compensation for accidents abroad, clinical negligence, and costs protections. Specifically, it discusses an overturned decision related to determining additional needs caused by negligence for a claimant with pre-existing conditions. It also discusses cases related to withdrawing admissions of liability, applying foreign law for compensation for accidents abroad, assessing evidence in clinical negligence cases, and applying costs protections for claimants who change solicitors.
State of wash case mandatory arbitration clause in an insurance contract wa...Umesh Heendeniya
This case involves a dispute over whether arbitration clauses in two insurance policies issued by James River Insurance Company to the Washington State Department of Transportation (WSDOT) are enforceable. The trial court denied James River's motion to compel arbitration, finding the clauses violated state statutes prohibiting agreements that deprive state courts of jurisdiction over actions against insurers. The Supreme Court of Washington affirms, finding that the statutes are intended to protect the right to bring an original action in state court and that binding arbitration deprives courts of jurisdiction to consider the substance of disputes.
This document summarizes a Supreme Court case from the Philippines regarding a car accident.
Priscilla Rodriguez was struck by a passenger bus while crossing the street. She sued the bus company, who had an insurance policy with Western Guaranty Corporation. The trial court found the bus company and insurer liable and awarded damages. Western Guaranty appealed, arguing its liability was limited by the schedule of indemnities in the policy.
The Supreme Court upheld the appellate court's decision. It found the schedule did not limit the types of damages that could be awarded, only monetary amounts for specific injuries. The policy stated the insurer was liable for "all sums necessary" for bodily injury to third parties. Therefore, Western Guaranty
This document is a Supreme Court of the Philippines decision regarding whether an insurance company's security deposit held by the Insurance Commissioner can be levied or garnished in favor of a single insured claimant. The Court ruled that the security deposit is intended to protect all policyholders and cannot be garnished by a single claimant. It summarized that the Commissioner's refusal to release the deposit was proper given his duty to regulate the insurance industry and protect all insureds. The Court found the trial court erred in holding the Commissioner in contempt for refusing to comply with its order allowing garnishment of the deposit.
Trial Strategy: The Struggle over Perpetuating Testimony Before Litigation B...NationalUnderwriter
Can an insurance company seek a court order to protect evidence before it is sued by a policyholder? A carrier may want to do this to protect its interests in any coverage case that ultimately is filed. Several decisions by federal district courts in Louisiana have explored this topic – and have reached different conclusions.
The document provides instructions for Department of Navy (DON) personnel to file claims for personal property losses due to incidents like fire, flood, theft, or vandalism. It outlines who can file a claim, the deadlines, required forms and documentation, as well as the claims process and payment methods. Claimants must submit their claim on a DD Form 1842 and DD Form 1844, along with documents like a police report, proof of attempts to file with private insurance, replacement/repair estimates, and photographs of damaged items. The claim will be processed according to the Military Personnel and Civilian Employees Claims Act and claimants will be reimbursed up to the fair market value of damaged or lost items.
the Supreme Court has reversed the Court of Appeals in this case (and the companion Floyd case), ruling that an injured person is not entitled to reduce available liability coverage by the amount of a statutory medical lien in order to increase available UM benefits. The decision is attached. The court did not disturb the underlying rationale of Thurman and Toomer but simply distinguished hospital liens from the federal subrogation claims present in those cases.
This newsletter provides updates on recent cases related to personal injury law. In Montgomery v Lanarkshire Health Board, the Supreme Court overturned previous rulings and found that patients should be made aware of any material medical risks or alternative treatments. In road traffic cases, a recent EU court ruling found that insurance must cover any vehicle use consistent with its normal function, placing more claims under the MIB agreement. Two psychiatric injury cases reaffirmed that employers are not responsible for stress claims without notice of particular vulnerabilities and damages for shock require witnessing a horrifying event directly.
This document provides a summary of recent developments in personal injury law from November 2015. It discusses cases related to causation of loss, withdrawal of admission, compensation for accidents abroad, clinical negligence, and costs protections. Specifically, it discusses an overturned decision related to determining additional needs caused by negligence for a claimant with pre-existing conditions. It also discusses cases related to withdrawing admissions of liability, applying foreign law for compensation for accidents abroad, assessing evidence in clinical negligence cases, and applying costs protections for claimants who change solicitors.
State of wash case mandatory arbitration clause in an insurance contract wa...Umesh Heendeniya
This case involves a dispute over whether arbitration clauses in two insurance policies issued by James River Insurance Company to the Washington State Department of Transportation (WSDOT) are enforceable. The trial court denied James River's motion to compel arbitration, finding the clauses violated state statutes prohibiting agreements that deprive state courts of jurisdiction over actions against insurers. The Supreme Court of Washington affirms, finding that the statutes are intended to protect the right to bring an original action in state court and that binding arbitration deprives courts of jurisdiction to consider the substance of disputes.
This document summarizes a Supreme Court case from the Philippines regarding a car accident.
Priscilla Rodriguez was struck by a passenger bus while crossing the street. She sued the bus company, who had an insurance policy with Western Guaranty Corporation. The trial court found the bus company and insurer liable and awarded damages. Western Guaranty appealed, arguing its liability was limited by the schedule of indemnities in the policy.
The Supreme Court upheld the appellate court's decision. It found the schedule did not limit the types of damages that could be awarded, only monetary amounts for specific injuries. The policy stated the insurer was liable for "all sums necessary" for bodily injury to third parties. Therefore, Western Guaranty
This document is a Supreme Court of the Philippines decision regarding whether an insurance company's security deposit held by the Insurance Commissioner can be levied or garnished in favor of a single insured claimant. The Court ruled that the security deposit is intended to protect all policyholders and cannot be garnished by a single claimant. It summarized that the Commissioner's refusal to release the deposit was proper given his duty to regulate the insurance industry and protect all insureds. The Court found the trial court erred in holding the Commissioner in contempt for refusing to comply with its order allowing garnishment of the deposit.
Trial Strategy: The Struggle over Perpetuating Testimony Before Litigation B...NationalUnderwriter
Can an insurance company seek a court order to protect evidence before it is sued by a policyholder? A carrier may want to do this to protect its interests in any coverage case that ultimately is filed. Several decisions by federal district courts in Louisiana have explored this topic – and have reached different conclusions.
The document provides instructions for Department of Navy (DON) personnel to file claims for personal property losses due to incidents like fire, flood, theft, or vandalism. It outlines who can file a claim, the deadlines, required forms and documentation, as well as the claims process and payment methods. Claimants must submit their claim on a DD Form 1842 and DD Form 1844, along with documents like a police report, proof of attempts to file with private insurance, replacement/repair estimates, and photographs of damaged items. The claim will be processed according to the Military Personnel and Civilian Employees Claims Act and claimants will be reimbursed up to the fair market value of damaged or lost items.
the Supreme Court has reversed the Court of Appeals in this case (and the companion Floyd case), ruling that an injured person is not entitled to reduce available liability coverage by the amount of a statutory medical lien in order to increase available UM benefits. The decision is attached. The court did not disturb the underlying rationale of Thurman and Toomer but simply distinguished hospital liens from the federal subrogation claims present in those cases.
This document is a court ruling on an appeal regarding a workers' compensation lien. It summarizes that the plaintiff, Meredith Donatello, was injured while working and received $21,637.38 in workers' compensation benefits. She later settled a third-party liability claim for $25,000. The workers' compensation insurer, SEJIF, placed a lien on the settlement for reimbursement. The plaintiff argued medical expenses and potential lost wages should be excluded from the lien. However, the court affirmed the lower court ruling, finding the clear language of N.J.S.A. 34:15-40 entitles the insurer to reimbursement for all benefits paid without exclusions.
The Supreme Court granted the petition of the Republic of the Philippines, represented by Insurance Commissioner Eduardo T. Malinis, to reverse the order of contempt issued by the Regional Trial Court against the commissioner. The trial court ordered the release of the security deposit held by the Insurance Commission from Capital Insurance and Surety Co. to satisfy a garnishment notice in favor of a single claimant, Del Monte Motors. However, the Supreme Court ruled that the security deposit is intended to answer for claims of all policyholders if the insurance company becomes insolvent, and cannot be garnished by a single claimant to the detriment of others. As the commissioner's refusal to release the funds was justified and in accordance with his authority to regulate
This newsletter summarizes recent reinsurance case law developments. The first case discusses an 8th Circuit ruling that an endorsement incorporating a jurisdictional clause superseded an alternative dispute resolution clause. The second case discusses a New Jersey ruling staying litigation in favor of arbitration over an alleged breach involving an offset dispute. The third case discusses an Illinois ruling dismissing an assignee's request for pre-answer security and motion to compel arbitration against a sovereign-owned reinsurer.
This document is a status report from the Claims Administrator of the Deepwater Horizon Economic and Property Damages Settlement Agreement to the United States District Court for the Eastern District of Louisiana. It provides updates on the number of claims submitted and reviewed, the identity verification and review processes, exclusions reviews, accounting support reviews, and quality assurance reviews being conducted. The report aims to inform the Court on the current status of implementing the Settlement Agreement.
Life Insurer's Liability for Actions of Its Producer--Even before Producer's ...NationalUnderwriter
The Supreme Judicial Court of Maine has affirmed a lower court’s decision upholding the Maine Superintendent of
Insurance’s conclusion that Guarantee Trust Life Insurance Company (“GTL”) was accountable for violations of a number of Maine statutes by a company acting as GTL’s producer – even before the company’s formal appointment as GTL’s producer. As a result, the court upheld the Superintendent’s order that GTL pay a civil penalty of $150,000.
Confessions of Judgement in Kyko Global Inc vs Madhavi Vuppalapati & Prithvi ...mh37o
The judgement was passed in favour of Plaintiffs Kyko Global Inc. Confessions of Judgement in Kyko Global Inc vs Madhavi Vuppalapati & Prithvi Info Solutions Ltd
Kindred Kentucky Supreme Court 16 32-op-bel-kyZ Research
The Supreme Court denied interlocutory relief to two nursing homes seeking to compel arbitration based on arbitration agreements signed by attorneys-in-fact during admission to the nursing homes. The Court found that the power-of-attorney instruments did not grant the attorneys-in-fact authority to waive the residents' right to access the courts. Additionally, the Court reaffirmed that wrongful death beneficiaries cannot be bound by arbitration agreements signed on behalf of the deceased.
Bad Faith Insurance Law Overview, Oregon Alaska Idaho MontanaSeth Row
This document summarizes bad faith law in the Pacific Northwest states of Oregon, Alaska, Idaho, and Montana. It outlines the requirements to bring a bad faith claim in each state, such as needing a special relationship in Oregon or the claim not being fairly debatable in Idaho. The standard of care expected of insurers is also discussed for each state, for example, acting as an ordinarily prudent insurer would in Oregon. Potential remedies like damages, attorney fees, and estoppel are mentioned for the different states. Contact information is provided for the authors at the end.
Studio 417 inc. v. the cincinnati insuranceBolinLawGroup
This order denies the defendant insurance company's motion to dismiss. The plaintiffs, who are businesses that own restaurants and hair salons, filed a lawsuit against their insurance provider seeking coverage for losses they incurred when the businesses were forced to close due to the COVID-19 pandemic. The defendant argued that the insurance policies required "physical loss or damage" and that COVID-19 does not cause such physical alterations. However, the court found that the policies do not define "physical loss" and its plain meaning could include loss of use, which the plaintiffs allegedly experienced when they were prohibited from operating their businesses. Therefore, the plaintiffs adequately stated claims under the various coverage provisions of the policies, and the defendant's motion to dismiss was denied.
This newsletter provides updates on recent personal injury cases in several areas of law. In breach of duty cases, the Court of Appeal found that a defendant's mental impairment does not eliminate responsibility if they fail to exercise reasonable care. In road traffic cases, a driver was found primarily liable for a collision with a cyclist for failing to pass with sufficient room. In clinical negligence, the Court of Appeal found no liability for psychiatric injury from witnessing deterioration over time rather than a sudden event. The newsletter also discusses child abuse claims and costs rulings.
This document is Defendant's brief in support of a motion for summary disposition in a case regarding a car accident. It argues that summary disposition is appropriate under MCR 2.116 (C)(10) and (C)(8) because Plaintiff cannot establish specific facts to support their claim or a valid legal basis for the claim. It also argues that no genuine issues of material fact exist regarding Defendant's liability under the Michigan No-Fault Act. The brief provides background on the standards for summary disposition and reviews the purpose and relevant sections of the Michigan No-Fault Act regarding insurance requirements.
This document is an objection filed by petitioning creditors BDCM Opportunity Fund II, LP, Black Diamond CLO 2005-1 Ltd., and Spectrum Investment Partners, LP in response to a motion by alleged debtors Allied Systems Holdings, Inc. and Allied Systems, Ltd. (L.P.) to transfer venue of involuntary bankruptcy cases from the U.S. Bankruptcy Court for the District of Delaware to the U.S. Bankruptcy Court for the Northern District of Georgia. The petitioning creditors argue that the motion to transfer venue is procedurally defective and substantively objectionable. They assert the motion is premature until an order for relief is entered, and the alleged debtors have not met their burden to show transfer is in the
The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration regarding a lien filed by Dr. Michael Newman for medical-legal reports he prepared. The primary treating physician, Dr. Massey, had designated Dr. Newman to prepare a permanent and stationary report. While Dr. Massey did not formally adopt Dr. Newman's findings until after the initial trial date, this did not preclude Dr. Newman from establishing his lien. Additionally, it was reasonable for Dr. Massey to designate a chiropractor like Dr. Newman for an evaluation, given the applicant's orthopedic injury and surgery. Finally, Dr. Newman was not required to participate in the initial trial, and properly objected when the defendant sought to
The Division of Workers Compensation and Workers' Compensation Appeals Board have amended forms and added new requirements for lien filings to comply with recent legislation. The changes include: (1) requiring an amended lien form including a declaration affirming eligibility under penalty of perjury; (2) requiring prior lien filings that require fees to submit a declaration by July 1, 2017 describing services provided; and (3) mandating that all lien claimants file an original bill with their lien starting January 1, 2017. Additionally, a revised attorney fee disclosure statement form was made available to comply with amended requirements.
This document summarizes a workers' compensation case involving letters sent by the applicant's attorney to three Agreed Medical Evaluators without the defendants' approval. The defendants filed a petition for removal, arguing the letters contained impermissible "information." The WCJ initially found the letters were only "communications," but then recommended removal was appropriate. The Appeals Board granted removal to determine whether the letters contained "information" requiring the defendants' approval under Labor Code section 4062.3. The Board noted removal is an extraordinary remedy, but was warranted here due to the potential for substantial prejudice and irreparable harm if biased medical evaluator reports resulted.
This document discusses photography and composition. It explains that photography plays an important role in visual communication, as seen in magazines like National Geographic and social media. The document instructs readers to locate a photograph using at least three design elements, such as balance, color or asymmetry, and explain how these elements impact the photograph. It provides examples of resources with photographs and an example analysis discussing asymmetry, line and color in a landscape photograph.
This short document lists the names of 6 photographers who have contributed photos: Mario Sepülveda, { pranav }, Poesia Vomitiva, HBakkali, jgoge, and kevin dooley. It concludes by encouraging the reader to create their own presentation on SlideShare.
Growth Enablers - Fifth P Industry ViewpointFifthP
This document discusses challenges facing businesses in managing performance in a difficult industry landscape. It outlines issues such as price deflation, increased competition, and changing consumer tastes. The document then proposes that CEOs can implement a new approach to clearly identify growth enablers versus detractors. This involves decomposing the P&L, evaluating business foundations and activities, and prioritizing the most impactful areas for change to reduce inefficiencies and drive growth. Interested parties are invited to contact the strategy consulting firm Fifth P to learn more about how they can help companies achieve clarity and implement improvement programs.
The document discusses the rise of grocery discounters and their impact on the grocery industry. It notes that discounters are establishing themselves as the new price barometers and intensifying price competition. This is eroding profit margins across the industry as retailers pressure suppliers to further fuel the price war. The document provides strategies for suppliers to take leadership in price positioning, including establishing well-considered price corridors for their products in discounters versus grocery stores. It also recommends empowering sales teams to proactively manage pricing strategies rather than reacting to competitors.
This document is a court ruling on an appeal regarding a workers' compensation lien. It summarizes that the plaintiff, Meredith Donatello, was injured while working and received $21,637.38 in workers' compensation benefits. She later settled a third-party liability claim for $25,000. The workers' compensation insurer, SEJIF, placed a lien on the settlement for reimbursement. The plaintiff argued medical expenses and potential lost wages should be excluded from the lien. However, the court affirmed the lower court ruling, finding the clear language of N.J.S.A. 34:15-40 entitles the insurer to reimbursement for all benefits paid without exclusions.
The Supreme Court granted the petition of the Republic of the Philippines, represented by Insurance Commissioner Eduardo T. Malinis, to reverse the order of contempt issued by the Regional Trial Court against the commissioner. The trial court ordered the release of the security deposit held by the Insurance Commission from Capital Insurance and Surety Co. to satisfy a garnishment notice in favor of a single claimant, Del Monte Motors. However, the Supreme Court ruled that the security deposit is intended to answer for claims of all policyholders if the insurance company becomes insolvent, and cannot be garnished by a single claimant to the detriment of others. As the commissioner's refusal to release the funds was justified and in accordance with his authority to regulate
This newsletter summarizes recent reinsurance case law developments. The first case discusses an 8th Circuit ruling that an endorsement incorporating a jurisdictional clause superseded an alternative dispute resolution clause. The second case discusses a New Jersey ruling staying litigation in favor of arbitration over an alleged breach involving an offset dispute. The third case discusses an Illinois ruling dismissing an assignee's request for pre-answer security and motion to compel arbitration against a sovereign-owned reinsurer.
This document is a status report from the Claims Administrator of the Deepwater Horizon Economic and Property Damages Settlement Agreement to the United States District Court for the Eastern District of Louisiana. It provides updates on the number of claims submitted and reviewed, the identity verification and review processes, exclusions reviews, accounting support reviews, and quality assurance reviews being conducted. The report aims to inform the Court on the current status of implementing the Settlement Agreement.
Life Insurer's Liability for Actions of Its Producer--Even before Producer's ...NationalUnderwriter
The Supreme Judicial Court of Maine has affirmed a lower court’s decision upholding the Maine Superintendent of
Insurance’s conclusion that Guarantee Trust Life Insurance Company (“GTL”) was accountable for violations of a number of Maine statutes by a company acting as GTL’s producer – even before the company’s formal appointment as GTL’s producer. As a result, the court upheld the Superintendent’s order that GTL pay a civil penalty of $150,000.
Confessions of Judgement in Kyko Global Inc vs Madhavi Vuppalapati & Prithvi ...mh37o
The judgement was passed in favour of Plaintiffs Kyko Global Inc. Confessions of Judgement in Kyko Global Inc vs Madhavi Vuppalapati & Prithvi Info Solutions Ltd
Kindred Kentucky Supreme Court 16 32-op-bel-kyZ Research
The Supreme Court denied interlocutory relief to two nursing homes seeking to compel arbitration based on arbitration agreements signed by attorneys-in-fact during admission to the nursing homes. The Court found that the power-of-attorney instruments did not grant the attorneys-in-fact authority to waive the residents' right to access the courts. Additionally, the Court reaffirmed that wrongful death beneficiaries cannot be bound by arbitration agreements signed on behalf of the deceased.
Bad Faith Insurance Law Overview, Oregon Alaska Idaho MontanaSeth Row
This document summarizes bad faith law in the Pacific Northwest states of Oregon, Alaska, Idaho, and Montana. It outlines the requirements to bring a bad faith claim in each state, such as needing a special relationship in Oregon or the claim not being fairly debatable in Idaho. The standard of care expected of insurers is also discussed for each state, for example, acting as an ordinarily prudent insurer would in Oregon. Potential remedies like damages, attorney fees, and estoppel are mentioned for the different states. Contact information is provided for the authors at the end.
Studio 417 inc. v. the cincinnati insuranceBolinLawGroup
This order denies the defendant insurance company's motion to dismiss. The plaintiffs, who are businesses that own restaurants and hair salons, filed a lawsuit against their insurance provider seeking coverage for losses they incurred when the businesses were forced to close due to the COVID-19 pandemic. The defendant argued that the insurance policies required "physical loss or damage" and that COVID-19 does not cause such physical alterations. However, the court found that the policies do not define "physical loss" and its plain meaning could include loss of use, which the plaintiffs allegedly experienced when they were prohibited from operating their businesses. Therefore, the plaintiffs adequately stated claims under the various coverage provisions of the policies, and the defendant's motion to dismiss was denied.
This newsletter provides updates on recent personal injury cases in several areas of law. In breach of duty cases, the Court of Appeal found that a defendant's mental impairment does not eliminate responsibility if they fail to exercise reasonable care. In road traffic cases, a driver was found primarily liable for a collision with a cyclist for failing to pass with sufficient room. In clinical negligence, the Court of Appeal found no liability for psychiatric injury from witnessing deterioration over time rather than a sudden event. The newsletter also discusses child abuse claims and costs rulings.
This document is Defendant's brief in support of a motion for summary disposition in a case regarding a car accident. It argues that summary disposition is appropriate under MCR 2.116 (C)(10) and (C)(8) because Plaintiff cannot establish specific facts to support their claim or a valid legal basis for the claim. It also argues that no genuine issues of material fact exist regarding Defendant's liability under the Michigan No-Fault Act. The brief provides background on the standards for summary disposition and reviews the purpose and relevant sections of the Michigan No-Fault Act regarding insurance requirements.
This document is an objection filed by petitioning creditors BDCM Opportunity Fund II, LP, Black Diamond CLO 2005-1 Ltd., and Spectrum Investment Partners, LP in response to a motion by alleged debtors Allied Systems Holdings, Inc. and Allied Systems, Ltd. (L.P.) to transfer venue of involuntary bankruptcy cases from the U.S. Bankruptcy Court for the District of Delaware to the U.S. Bankruptcy Court for the Northern District of Georgia. The petitioning creditors argue that the motion to transfer venue is procedurally defective and substantively objectionable. They assert the motion is premature until an order for relief is entered, and the alleged debtors have not met their burden to show transfer is in the
The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration regarding a lien filed by Dr. Michael Newman for medical-legal reports he prepared. The primary treating physician, Dr. Massey, had designated Dr. Newman to prepare a permanent and stationary report. While Dr. Massey did not formally adopt Dr. Newman's findings until after the initial trial date, this did not preclude Dr. Newman from establishing his lien. Additionally, it was reasonable for Dr. Massey to designate a chiropractor like Dr. Newman for an evaluation, given the applicant's orthopedic injury and surgery. Finally, Dr. Newman was not required to participate in the initial trial, and properly objected when the defendant sought to
The Division of Workers Compensation and Workers' Compensation Appeals Board have amended forms and added new requirements for lien filings to comply with recent legislation. The changes include: (1) requiring an amended lien form including a declaration affirming eligibility under penalty of perjury; (2) requiring prior lien filings that require fees to submit a declaration by July 1, 2017 describing services provided; and (3) mandating that all lien claimants file an original bill with their lien starting January 1, 2017. Additionally, a revised attorney fee disclosure statement form was made available to comply with amended requirements.
This document summarizes a workers' compensation case involving letters sent by the applicant's attorney to three Agreed Medical Evaluators without the defendants' approval. The defendants filed a petition for removal, arguing the letters contained impermissible "information." The WCJ initially found the letters were only "communications," but then recommended removal was appropriate. The Appeals Board granted removal to determine whether the letters contained "information" requiring the defendants' approval under Labor Code section 4062.3. The Board noted removal is an extraordinary remedy, but was warranted here due to the potential for substantial prejudice and irreparable harm if biased medical evaluator reports resulted.
This document discusses photography and composition. It explains that photography plays an important role in visual communication, as seen in magazines like National Geographic and social media. The document instructs readers to locate a photograph using at least three design elements, such as balance, color or asymmetry, and explain how these elements impact the photograph. It provides examples of resources with photographs and an example analysis discussing asymmetry, line and color in a landscape photograph.
This short document lists the names of 6 photographers who have contributed photos: Mario Sepülveda, { pranav }, Poesia Vomitiva, HBakkali, jgoge, and kevin dooley. It concludes by encouraging the reader to create their own presentation on SlideShare.
Growth Enablers - Fifth P Industry ViewpointFifthP
This document discusses challenges facing businesses in managing performance in a difficult industry landscape. It outlines issues such as price deflation, increased competition, and changing consumer tastes. The document then proposes that CEOs can implement a new approach to clearly identify growth enablers versus detractors. This involves decomposing the P&L, evaluating business foundations and activities, and prioritizing the most impactful areas for change to reduce inefficiencies and drive growth. Interested parties are invited to contact the strategy consulting firm Fifth P to learn more about how they can help companies achieve clarity and implement improvement programs.
The document discusses the rise of grocery discounters and their impact on the grocery industry. It notes that discounters are establishing themselves as the new price barometers and intensifying price competition. This is eroding profit margins across the industry as retailers pressure suppliers to further fuel the price war. The document provides strategies for suppliers to take leadership in price positioning, including establishing well-considered price corridors for their products in discounters versus grocery stores. It also recommends empowering sales teams to proactively manage pricing strategies rather than reacting to competitors.
This short document promotes creating presentations using Haiku Deck, a tool for making slideshows. It encourages the reader to get started making their own Haiku Deck presentation and sharing it on SlideShare. In just one sentence, it pitches the idea of using Haiku Deck to easily create engaging slideshows.
The Workers' Compensation Appeals Board affirmed the decision that the medical lien claimant's lien was barred. [The lien claimant provided medical services to the applicant from April to August 2013.] The Board found that under section 4903.5(a) of the Labor Code, the lien claimant was required to file its lien within 18 months of the last date of service in August 2013, but failed to do so. [The Board rejected the lien claimant's argument that the three-year limitation period applied instead of the 18-month period.] The 18-month limitation period enacted in January 2013 provided lien claimants with reasonable time to timely file liens for services provided on or after July 1, 2013.
1. The document discusses the time limits for filing liens under California law, both before and after 2013 reforms.
2. Prior to 2013, lien claimants had 6 months after learning of an industrial injury to file a lien. The reforms in 2013 changed this to 12 months and removed healthcare providers from those able to file liens.
3. For services provided for future medical treatment or where the case was settled prior to 2013, the lien filing deadlines and rules in effect at that time would apply rather than the current laws.
Pricing strategy - Fifth P Industry ViewpointFifthP
1. The document discusses the need for pricing strategy to evolve into a core strategic asset for driving growth against a challenging market backdrop.
2. Currently, pricing is often too tactical and designed from the bottom-up, but it needs to change and become a strategic growth lever by developing the right price and range across the portfolio from a consumer-focused lens.
3. Leading success in pricing strategy requires taking a strategic step-change by transforming pricing into a strategic capability, developing the right prices based on consumer insights, evolving price positioning across channels, and enhancing innovation with increased commercial analysis.
This document provides information about California's independent bill review process established under SB 863. It includes a quick reference guide to the rules governing the IBR process with 14 pages of content and timelines. The document also contains 6 flowcharts illustrating the steps in the IBR process. It was created by Richard Boggan, an attorney, as a reference for understanding how the IBR system works according to the emergency regulations.
This document discusses challenges facing CEOs in managing business performance and growth in a difficult industry landscape. It proposes that CEOs can cut through complexity by implementing a repeatable process to evaluate how business foundations impact growth. This includes impartially assessing capabilities, collecting qualitative team statements, and identifying the most impactful external and internal growth enablers and detractors. The outcome would be a prioritized list of issues to focus improvement programmes and achieve greater clarity on what truly drives growth. Implementing this approach could help companies effectively navigate challenges and achieve sustainable long-term growth.
The document is a cover letter and resume from Balendra Prasad Pandey applying for a D.S. Manager position. The cover letter highlights his 23 years of experience in sales, operations, and management. His resume then details his educational and professional background, including current and previous roles in sales management, business development, and operations management for various consumer goods companies. It outlines his responsibilities, achievements, and qualifications for the position.
This short document promotes creating presentations using Haiku Deck, a tool for making slideshows. It encourages the reader to get started making their own Haiku Deck presentation and sharing it on SlideShare. In just one sentence, it pitches the idea of using Haiku Deck to easily create engaging slideshows.
The document discusses chess pieces as metaphors for various aspects of the workers' compensation system.
The Queen represents medical-legal services, the Workers' Compensation Appeals Board (WCAB), and petitions. The Queen has many powerful tools and is the second most important piece in the game.
The Pawn represents billing and Explanation of Review (EOR) codes. Correct billing and understanding EOR codes are important for determining the nature and extent of a case - a mistake can make a case long and drawn out while doing it right can lead to an easy win.
Mental checklists using these chess piece metaphors are important for ensuring all relevant issues are considered in encounters like phone calls, settlements,
This document provides an overview of strategic concepts for provider disputes in workers' compensation. It compares key processes like UR, IBR, MPNs, and billing to chess pieces:
- The king represents the burden of proof, as the most important piece that must be protected.
- Medical-legal services, petitions, and the WCAB are like the powerful queen that can move across the board.
- IBR is analogous to rooks for covering wide ranges but with predictable moves.
- MPN issues are like knights that can jump over other pieces with an L-shaped move.
- UR and IMR processes are surprising like bishops that move diagonally across the board.
The document summarizes the Federal False Claims Act (FCA) and the Anti-Kickback Statute and how they relate. It notes that the FCA prohibits fraudulent claims to the government and provides incentives for whistleblowers. Recent cases have involved healthcare fraud through kickbacks disguised as improper lease or financial arrangements. Strict compliance with anti-kickback safe harbors is required to avoid penalties under the FCA or civil monetary penalties. Violation of the Anti-Kickback Statute can form the basis of a claim under the FCA.
The document discusses a response filed by the Killeen Independent School District to a petitioner's motion to quash a subpoena duces tecum and deposition on written questions for three individuals. The response argues that the petitioner's arguments for quashing the subpoena fail as a matter of law and that the motion to quash should be denied. It discusses the relevance of the information sought in the subpoena and deposition to the subject matter of the case and that the information is reasonably calculated to lead to admissible evidence. The response also argues that the petitioner misquoted rules of evidence in their motion.
This document provides an introduction to legal aspects of nursing, focusing on duty of care and negligence. It discusses several key points:
- Most English law is in the form of statutes passed by Parliament, while common law consists of legal precedents set by past court rulings.
- Nurses have both a professional and legal obligation under the NMC code to practice lawfully. Failing to follow laws or evidence-based guidelines could constitute negligence.
- For a claimant to prove negligence, they must show the nurse owed them a duty of care, breached that duty, and caused harm or loss. Duty of care and standards of care are determined through various legal precedents and rulings like Bolam and
Legal Proceedings Initiated Against Steven de Koenigswarter and Associated En...Theworld Crawler
Court order from the Superior Court of Justice in Ontario, Canada. The order is dated July 4, 2023, and it is addressed to Steven de Koenigswarter, Luc Georges de Clerck, the de Koenigswarter Family Trust, the Health Factory Holding BV, and Venator International SA.
The order states that a legal proceeding has been commenced against the defendants by the plaintiff, 2705564 Ontario Inc. The claim made against the defendants is set out in the statement of claim that was served with the notice of action
Presentation on key issues in tax law for employment cases including employment discrimination cases and other common termination scenarios. Prepared by Robert B. Fitzpatrick of Robert B. Fitzpatrick, PLLC for use in Current Developments in Employment Law, an annual CLE program, in July of 2016.
This document summarizes various fraud and abuse laws including the Federal False Claims Act, the Stark laws, and the Federal Anti-Kickback Statute. It provides an overview of these laws and regulations, details penalties for noncompliance, and discusses recent case law examples. The document also covers compliance issues and exceptions like the physician recruitment safe harbor.
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14. Meeting Burden of Proof Denied
Case
Luis Gonzalez (Luis Gonzalez Valladeres), Applicant v. San Cristobal
Distributing, State Compensation Insurance Fund, Defendants No.
ADJ6448504 (Panel Decision)Opinion Filed November 12, 2010 which held:
“When an applicant's case is resolved by a compromise and release with no
admission of liability, a lien claimant has the burden to establish a prima facie
case of industrial injury. After a prima facie case is presented, the burden shifts
to the defendant to rebut the prima facie showing. (Pace Medical Group, inc. v.
Workers' Comp. Appeals Bd. (Valiente) (1994) 59 Cal.Comp.Cases 354, 356
([writ denied].) Contrary to the defendant's argument, it is well established that
a lien claimant can carry its burden by introducing hearsay statements in
medical records, and it is not required to prove its case by presenting an
injured worker's testimony. (Independence Indem. Co. v. IAC (Lohnes) (1935)
2 Cal.2d 397, 410 [20 IAC 311]; Lab. Code, §5708.)
12/11/2016 www.workcompliens.com 14
15. Defective Notices –Resulting In
Unreasonable Offer of Care
Bruce Knight, United Parcel Service; and
Liberty Mutual Insurance Company October 10,
2006 71 Cal. Comp. Cases 1423
“The Board held that an employer or insurer's
failure to provide required notice to an employee of
rights under the MPN (medical provider network)
that results in a neglect or refusal to provide
reasonable medical treatment renders the employer
or insurer liable for reasonable medical treatment
self-procured by the employee.
16.
17. 9767.9. Transfer of Ongoing Care
into the MPN
9767.9 (j) If the treating physician does not agree
with the employer's or insurer's determination
that the injured covered employee's medical
condition does not meet the conditions set forth
in subdivisions (e)(1) through (e)(4), the transfer
of care shall not go forward until the dispute is
resolved.
Big issue for providers, they are ignoring these notice
to transfer into MPN when all they had to do was
object to make it an none issue and continue to treat
until resolved by the WCAB
18.
19. The King is defined as the burden
of proof.
The King is defined as the burden of proof. The reason is, that if the King is
captured or more correctly checkmated, it ends the game, although not the
most powerful piece as it can only move one space at a time in any direction
(exception, castling ), it is the most important piece, as without it, the game is
over. In workers comp, based on the 2012 en banc "Torres" case, although a
WCAB decision, all stages and or processes involved in a Provides' dispute,
revolves around the burden of proof. From medical reports justify billing
codes, medical facts in medical reports for authorization, overcoming MPNs
and most importantly, issues at the WCAB, all are determined based on
the burden of proof, without it you lose, with it and the game is won. From the
start to the end of the game, one always protects the King, using pawns and or
any other piece to accomplish that. Thus like workers comp, from the start,
you use other processes and evidence to develop your burden of proof
20. The King is defined as the burden
of proof.
The King is defined as the burden of proof. The reason is, that if the King is
captured or more correctly checkmated, it ends the game, although not the
most powerful piece as it can only move one space at a time in any direction
(exception, castling ), it is the most important piece, as without it, the game is
over. In workers comp, based on the 2012 en banc "Torres" case, although a
WCAB decision, all stages and or processes involved in a Provides' dispute,
revolves around the burden of proof. From medical reports justify billing
codes, medical facts in medical reports for authorization, overcoming MPNs
and most importantly, issues at the WCAB, all are determined based on
the burden of proof, without it you lose, with it and the game is won. From the
start to the end of the game, one always protects the King, using pawns and or
any other piece to accomplish that. Thus like workers comp, from the start,
you use other processes and evidence to develop your burden of proof
21. The Queen is defined as, Medical-
Legal, WCAB and Petitions.
The Queen is defined as, Medical-Legal, WCAB and Petitions. The Queen is the most
powerful piece in the game, although many a games are won without it, one does not let it
go easily, as it can move like any piece on the board, except the knight, that can jump over
pieces. In workers comp, Medical-Legal services / disputes have a carve out, outside the
requirement of normal authorization, not subject to MPN rules and defenses, not subject to
the determination of the case-in-chief, nor subject to lien fees and time limits, making
medical-legal services the most powerful of all services in workers comp. Only a master
chessman or chess-woman, truly knows the importance of the Queen and how to
maximizes its function and power. Because of the many powerful tools in workers comp, I
added to the Queen, the WCAB, Appeals and Petitions, as the additional power tools of the
Queen. Petitions; the Director through the medical unit of the DWC is in control and the
watch dog of the UR, IBR, second review and IMR Process, of which several Petitions and
appeals can be filed, both defined and those yet to be defined. This process is to ensure the
King (burden of proof), is not compromised by fouls in the game. The Queen, also defines
the WCAB, with the massive influx of laws, a tremendous amount of case law should be
being created as to the interpretation and function of the new laws, of which is presently
lacking, thus the lack of the use of the queen.
22. The Queen is defined as, Medical-
Legal, WCAB and Petitions.
The Queen is defined as, Medical-Legal, WCAB and Petitions. The Queen is the most
powerful piece in the game, although many a games are won without it, one does not let it
go easily, as it can move like any piece on the board, except the knight, that can jump over
pieces. In workers comp, Medical-Legal services / disputes have a carve out, outside the
requirement of normal authorization, not subject to MPN rules and defenses, not subject to
the determination of the case-in-chief, nor subject to lien fees and time limits, making
medical-legal services the most powerful of all services in workers comp. Only a master
chessman or chess-woman, truly knows the importance of the Queen and how to
maximizes its function and power. Because of the many powerful tools in workers comp, I
added to the Queen, the WCAB, Appeals and Petitions, as the additional power tools of the
Queen. Petitions; the Director through the medical unit of the DWC is in control and the
watch dog of the UR, IBR, second review and IMR Process, of which several Petitions and
appeals can be filed, both defined and those yet to be defined. This process is to ensure the
King (burden of proof), is not compromised by fouls in the game. The Queen, also defines
the WCAB, with the massive influx of laws, a tremendous amount of case law should be
being created as to the interpretation and function of the new laws, of which is presently
lacking, thus the lack of the use of the queen.
23. §10451.1. Determination of Medical-
Legal Expense Disputes.
PETITIONS
The following procedures shall be utilized for the determination of medical-legal expense disputes.
(b) For purposes of this section:
(1) “medical-legal expense” shall mean any cost or expense incurred by or on behalf of any party for the
purpose of proving or disproving a contested claim, including but not limited to:
(A) goods or services expressly specified by Labor Code section 4620(a);
(B) services rendered by a non-medical expert witness;
(C) services rendered by a certified interpreter during a medical-legal examination; and
(D) all costs or expenses for copying and related services.
(2) “medical-legal provider” shall mean any person or entity that seeks payment for or reimbursement of
a medical-legal expense, other than an employee, a dependent, or the attorney or non-attorney
representative of an employee or dependent who directly paid for medical-legal goods or services.
(c) Medical-Legal Expense Disputes Not Subject to Independent Bill Review
24. § 10301. Definitions(dd) “Party”
means
§ 10301. Definitions(dd) “Party” means: (1) a person claiming to be an
injured employee or the dependent of a deceased employee; (2) a
defendant; (3) an appellant from an independent medical review or
independent bill review decision or an injured employee or
provider seeking to enforce such a decision; (4) a medical-legal
provider involved in a medical-legal dispute not subject to independent
bill review; (5) an interpreter filing a petition for costs in accordance
with section 10451.3; or (6) a lien claimant where either (A) the
underlying case of the injured employee or the dependent(s) of a
deceased employee has been resolved or (B) the injured employee or
the dependent(s) of a deceased employee choose(s) not to proceed with
his, her, or their case.
25. Case Law
The definition of "contested claim" is varied, and can mean any of the
following: a rejected claim; a presumptively compensable claim; a
claim where temporary disability has not timely commenced or has not
issued a timely notice of delay; a claim where liability is accepted but
there are disputed medical facts.
If the PTP is requested by a "party" (applicant, Applicant Attorney,
Insurance), to do a P&S, a consultation , or any other report regarding
a "contested claim" , the PTP can then request (designate) and transfer
that request by a "party", to a another Provider (different specialty say a
psych which would include all necessary testing) to perform a Medical
Legal, and then those services are treated as a Medical- Legal and paid
as the same under the medical-legal fee schedule not the OMFS.
26.
27. Case Law
En Banc Decisions of Warren Brower v David Jones
Construction; State Compensation Insurance Fund May 21,
2014 Case No: ADJ802221 (SJO 0258870) 79 Cal. Comp.
Cases 550
In a recent En Banc Decision the Court Held: Moreover, a
medical-legal expense is ordinarily allowable if it is capable of
proving or disproving a contested claim, if the expense was
reasonably necessary at the time incurred, and if the cost
incurred was reasonable. (§§ 4620 et seq., 5307.6.) The mere
fact that the parties had agreed to an AME in a particular
specialty does not mean that a party cannot reasonably obtain a
comprehensive medical-legal report from a treating physician
in the same or similar specialty
31. The Rook
The Rook or slang, castle (because it looks like a castle) , is defined as, the
IBR process and fee schedule issues. The castle is a strong and powerful piece
and each player has two. The rook can move forward and backward or from
side to side and covers a wide range of the board. However, because of its
limited function, all players always look to see where the rook is, thus few
surprises, as it is more of a matter of fact piece. The IBR process is a powerful
tool and regardless of the $195.00 fee, it has to be used, because of the several
IBR decisions already posted, going to the IBR and knowing the results before
hand should be no surprise. However, mastering the rook is knowing how the
rook has been played in other games to achieve a wining game, i.e. sometimes
it addresses; authorization issues, PPO issues and usual and customary, making
those who read the IBR decisions a master of playing the rook, for winning
moves
33. Why One Is Right
"Lien claimant, Passages Malibu, seeks reconsideration and removal
from the Findings and Award, issued July 1, 2015,- in which a workers'
compensation administrative law judge (WCJ) ordered defendant
Liberty Mutual/Wausau, to pay lien claimant the sum of $272,533.26,
as the reasonable value of the services provided to applicant Bruno
Sabato, less credit for sums paid. Lien claimant contends the WCJ's
finding of the reasonable value of lien claimant's services is
not substantiated by the evidence, and requests that the Appeals Board
remove this matter to itself and find that it is entitled to payment of
$1,130,975.60. Lien claimant contends that there is no dispute as to its
entitlement for payment as defendant pre-authorized 300 days of
services at its residential treatment
facility."
34. ML104-95 Evaluation, 96101 and 96118 Psychological Testing
performed on Injured Worker 10/07/2014
ISSUE IN DISPUTE: Provider seeking remuneration for ML104-95 Evaluation, 96101
and 96118 Psychological Testing performed on Injured Worker 10/07/2014.
Claims Administrator reimbursed $0.00 of $6,331.45 with the following rational:
Claim denied and is currently in litigation.
May 29, 2014 Letter from Claims Admin Legal parties, addressed to the Provider
indicated the following: Defendants do not believe that the applicant is entitled to a
Psychiatric Panel at this time.
August 12, 2014 Letter to Provider from Claimants Attorney requesting PQM
Psychological Evaluation to include Causation and Apportionment.
Court Order, 07/17/2014, signed by Workers Compensation Administrative Law Judge
Granted the following: Applicant to go to PQME Eval w/ (Provider) to resolve psych
issues.
Provider is the PQME evaluator stated in the court order
36. 96118-59 and 9611-59
Claims Administrator denied codes indicating on the Explanation of Review Payment based on
individual pre-negotiated agreement for this specific service and Service exceeds agreed utilization
Letter dated 02/25/2015 from Utilization Review authorized 6 units Neuropsych Testing by TE for
insomnia nos. Service dates from 02/25/2015 through 03/25/2015
96119 -Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory
Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report,
administered by technician, per hour of technician time, face-to-face
Interpretation and report by the technician were not found for this review. Therefore, documentation does
not support billed code 96119 and reimbursementis not warranted.
CPT 96118 -Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler
Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time,
both face-to-face time administering tests to the patient and time interpreting these test results and
preparing the report
Report dated March 25, 2015 titled Neuropsychological Evaluation signed by Provider above, documents
a consultation with the injured worker as 1.5 hours and 7 hours of interpretation & report writing by the
neuropsychologist
37.
38. 22848, 63012, 63044, 63047, and
63048
ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 22848, 63012,
63044,
63047, and 63048
Claims Administrator denied code 22848 indicating on the Explanation of Review
Per CCI Edits, the value of this procedure is included in the value of the comprehensive
procedure
If modifier column shows 1 for pair codes, if an approved modifier is appended to the
column 2 code and documentation is submitted to support the billed service, then the
edit may be overridden.
As a pair code exists between billed code 22848 and reimbursed code 27280, provider
did not apply a proper modifier to 22848 on the CMS 1500 form. Therefore,
reimbursement of 22848 is not warranted.
39. 22848, 63012, 63044, 63047, and
63048
CHAP8-CPTcodes60000-69999_final10312013.doc; NATIONAL CORRECT CODING
INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES Revision Date: 1/1/2014C. Nervous System: 18. A
laminectomy includes excision of all the posterior
vertebral components, and a laminotomy includes partial excision of posterior vertebral components. Since a laminectomy is a
more extensive procedure than a laminotomy, a laminotomy code should not be reported with a laminectomy code for the same
vertebra
Provider s report documents Next, decompressive laminectomies/facetectomies were performed from T12-S1. From T12-L3
laminotomies/laminectomies were performed
Reimbursement of codes 63047 and 63048 is warranted.
Reimbursement of 63044 is not warranted.
CPT 63012 was denied by Claims Administrator as �The submitted documentation does not support the service being billed
for. We will re-evaluate this upon receipt of clarifying information
63012 - Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and
nerve roots for spondylolisthesis, lumbar (Gill type procedure)
Provider s documentation describes At L4-5, a Gill-type procedure was performed
Reimbursement of 63012 is warranted.
40.
41. 63081, 63082-59 X 3, 22851-59 X 3, 69990-59,
and 76001-59
SSUE IN DISPUTE: Provider is dissatisfied with reimbursement of codes 63081, 63082 -
59 X 3, 22851-59 X 3, 69990-59, and 76001-59
Provider denied codes indicating on the Explanation of Review The charge for this
procedure was not paid since the value of this procedure is included/bundled within The
value of another procedure performed
Provider billed code 69990-59 along with reimbursed billed code 22554. Per NCCI Edit of
the pair code between these two states they are never to be billed together and a modifier is
not allowed to override the edit. As such, reimbursement of 69990 is not warranted.
Claims Administrator also denied code 76001-59, Fluoroscopy, physician or other
qualified health care professional time more than 1 hour, assisting a nonradiologic
physician or other qualified health care professional (eg, nephrostolithotomy, ERCP,
bronchoscopy, transbronchial biopsy)
Providers report submitted does not document 76001 and therefore, reimbursement is not
warranted for 76001.
42. 63081, 63082-59 X 3, 22851-59 X 3,
69990-59, and 76001-59
Provider also billed 3 units of 22851-59,Application of intervertebral biomechanical device(s) (eg,
synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to
code for primary procedure)which is documented in the providers report.
Reimbursement of 22851 x 3 is warranted.
Provider also billed 63081, Vertebral corpectomy (vertebral body resection), partial or complete, anterior
approach with decompression of spinal cord and/or nerve root(s); cervical, single segment
Providers report documents A partial corpectomy had to be carried out before we were able to remove the
posterior osteophyte and decompress the spinal cord because of the very narrow disc space
Reimbursement of 63081 is warranted.
Provider documents �The same happened at C4-5 as well where partial corpectomy had to be carried
out as well�which supports billed code 63802, Vertebral corpectomy (vertebral body resection), partial
or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each
additional segment (List separately in
addition to code for primary procedure) for 1 unit.
•
43.
44. CPT 97750,
ANALYSIS AND FINDING
Based on review of the case file the following is noted: ISSUE IN DISPUTE: Provider is dissatisfied
with denial of CPT 97750, Physical
performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15
minutes
EOR does not indicate 97750 as unauthorized but does state No separate payment was made because the
value of the service is included within the value of another service performed on the same day
EOR s received only show CPT code 97750 billed along with CMS 1500 form billing only 97750.
Provider s report submitted documents 2 hours spent face to face and 60 minutes of report preparation
Opportunity to Dispute sent to Claims Administrator 08/12/2015; response not yet received
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for
97750 x12
Provider states a 10% PPO discount is to be applied to reimbursement
45.
46. 97670 “Functional Capacity Evaluation ” No Value
99499 at Customary Charges $1,687.50 /2nd
$2,375.00
Claims Administrator denied code indicating on the Explanation of Review “The Official Medical Fee
Schedule does not list this code(97670). No payment is being made at this time. Please resubmit your
claim with the OMFS codes that best describe the service(s) provided and your supporting
documentation”
Report Entitled “Functional Capacity Evaluation” reflects date of service 1/19/2015 OMFS allows for
Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the
value assigned to a comparable procedure or analogous code. The comparable procedure or analogous
code should reflect similar amount of resources, such as practice expense, time, complexity, expertise,
etc. as required for the procedure performed.”A code used in Functional Capacity Evaluation has been
99499.
There is no allowance or comparable code listed under the OMFS for service billed with procedure code
99499 or, more specifically, a Functional Capacity Evaluation;
Initial payments was zero allowed order for payments of billed charges in the amount of $1,687.50.
The correct billing code for a Functional Capacity Evaluation, 99499
47. 97670 “Functional Capacity Evaluation ” No Value 99499 at
Customary Charges $1,687.50 /2nd $2,375.00
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider dissatisfied with reimbursement of code 97799-86
Based on review of the Physician’s Initial Evaluation, procedure code 97799-86 is substantiated as the Provider
documented services performed and Provider’s Usual and Customary charge.
The Physician Evaluation details the injured worker’s medical history, current medications, physical examination
including functional strength, range of motion, function movement and lifting, dynamic posture and stabilization,
psychological evaluation, treatment plan and a formal request for authorization, a thorough evaluation was performed on
this injured worker
Claims Administrator based its reimbursement of 97799 86 on97670. The OMFS does not list an allowance for 97799 or
97670; these are described as “By Report” codes.
Documents reviewed included the Request for Authorization of Medical Treatment for an Initial Interdisciplinary
Evaluation documenting Provider’s cost at $2500.00.
Utilization Review Decision letter documented: Approved Initial Evaluation from 10/30/2013 –11/30/2013 Per the
supplied PPO contract, covered services billed with a procedure code for which there is no assigned value, Provider shall
be reimbursed at 95% of Eligible billed charge $ 2375.00
48. ANALYSIS AND FINDING
Based on review of the case file the following is noted: ·
ISSUE IN DISPUTE: Provider dissatisfied with reimbursement of code 97799-30·
Provider was reimbursed $471.81and is seeking additional reimbursement of $923.13.·
Claims Administrator sent a partial payment in the amount of $471.81 indicating on the Explanation of Review:
“The charge exceeds the official medical Fee Schedule allowance. The charge has been adjusted to the
scheduled allowance.” and “The Fee Schedule does not include a value for the procedure code billed. An
allowance has been made which is based on charges for similar/comparable services. Reimbursement is based
on the applicable reimbursement fee schedule.”
Claims Administrator does not state which code the 97799-30 is based on. ·
Included in this review is the Authorization Request –F.C.E. as a Panel QME, dated 4/8/2014 from the Provider.
The Request shows the CPT Request with Fee’s as 97799-30, Functional Capacity Evaluation/Unlisted Code, in
the amount $1395.00.
·
Claims Administrator sent Approved notification for Functional Capacity Evaluation dated April 17, 2014.
Instructions included “Services will be paid pursuant to the Official Medical Fee Schedule or an appropriate
PPO Contract” and the Authorization will expire in 60 Days
.
97799-30
49. 97799-30
Physician’s Functional Capacity Evaluation report documents “Approximately 5 hours and 40 minutes of physical
testing, report preparation, research, calculations and editing were performed in the completion of this Functional
Capacity Evaluation.” Provider also states: “Completion of the intake forms, health-screening questionnaire, job demand
questionnaire, the history, interview and eMTAP required reading and writing, while sitting and took approximately 50
minutes to complete” as well as “The patient is slightly restricted upon standing for 90 minutes during the functional
capacity evaluation.”
·
The Provider documents the numerous tests performed on this patient including strength test, sitting and standing
tolerance, aerobic step test, hand functional tests, manual muscle testing of the upper and lower extremity, tendon
reflexes, abnormal sensation, lifting capacity and carrying test, pushing and pulling, activities of daily living, fine motor
dexterity, cool down and activity log, functional capacity assessment and the Physician’s Permanent and
Stationary Report.
·
CPT code 97799 is an unlisted code the Provider billed at $1395.00. Claims Administrator reimbursed a partial payment
of $ 471.81 but failed to report what this figure was based on. Therefore, CPT code 97750, Physical Performance Test or
Measurement (egMusculoskeletal, Functional Capacity) with written report, each 15 minutes best describes the procedure
demonstrated and will replace the 97799-30 billed by the Provider.
·
CPT 97750 is listed on the Official Medical Fee Schedule at $38.34/unit and the provider spent a total of 340 minutes or
23 units. 38.34 x 23 = 881.82, this will be the appropriate Official Medical Fee to use on this review
50.
51. OUTPATIENT FUNCTIONAL CAPACITY
EVALUATION (FCE):Overturned
Claims Administrator guideline: Decision based
on MTUS Chronic Pain Treatment Guidelines.
MAXIMUS guideline: Decision based on MTUS
ACOEM Chapter 5 Cornerstones of Disability
Prevention and Management Page(s): 89-92.
Decision based on Non-MTUS Citation Official
Disability Guidelines (ODG) Chapter Fitness for
Duty Chapter, FCE.
52. ACOEM guidelines
Decision rationale: ACOEM guidelines indicate there is a functional assessment tool available
and that is a Functional Capacity Evaluation, however, it does not address the criteria. As such,
secondary guidelines were sought. Official Disability Guidelines indicates that a Functional
Capacity Evaluation is appropriate when a worker has had prior unsuccessful attempts to return
to work, has conflicting medical reports, the patient had an injury that required a detailed
exploration of a workers abilities, a worker is close to maximum medical improvement and/or
additional or secondary conditions have been clarified. However, the evaluation should not be
performed if the main purpose is to determine a worker's effort or compliance or the worker has
returned to work and an ergonomic assessment has not been arranged. The clinical
documentation submitted for review indicated the patient had prior unsuccessful attempts to
Return to work and was close to maximum medical improvement. Given the above, the request
for a Functional Capacity Evaluation is medically necessary
53. EPIDURAL INJECTION
The criteria for the use of epidural steroid injections are as follows:
1) Radiculopathy must be documented by physical examination and corroborated by imaging studies
and/orelectrodiagnostic testing.
2) Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs and muscle
relaxants).3) Injections should be performed using fluoroscopy (live x-ray) for guidance.
4) If used for diagnostic purposes, a maximum of two injections should be performed. A second block is
notrecommended if there is inadequate response to the first block. Diagnostic blocks should be at an
interval of at least one to two weeks between injections.
5) No more than two nerve root levels should be injected using transforaminal blocks.
6) No more than one interlaminar level should be injected at one session.
7) In the therapeutic phase, repeat blocks should be based on continued objective documented pain and
functional improvement, including at least 50% pain relief with associated reduction of medication use
for six to eight weeks, with a general recommendation of no more than 4 blocks per region per year.
(Manchikanti,2003) (CMS, 2004) (Boswell, 2007) 8) Current research does not support a "series-of-
three" injections in either the diagnostic or therapeutic phase.
54. Elements:
• unresponsiveness to conservative treatment.
• imaging studies
• clear clinical signs of radiculopathy and non-corroborative findings on imaging,
Additional Injections:
• Objective Functional Improvement from prior injections The ODG identifies documentation of at least 50-70%
pain relief for six to eight weeks, with a general recommendation of no more than four blocks per region per year, as well
as decreased need for pain medications, and functional response as criteria necessary to support the medical necessity of
additional epidural steroid injections.
Common Mistakes
• lack of documentation indicating the injured worker had radiating pain with the straight leg raise.•
• lack of documentation of failure of conservative care.
• failed to indicate the laterality, as well as the level for the injection
• no indication for failed conservative trial for diagnoses of cervicalgia and cervical
• no imaging studies provided for review.
• no documentation of unresponsiveness to conservative treatment.
• no more than 2 joint levels are injected in one session is recommended
• no documentation of at least 50-70% pain relief for six to eight weeks following previous injection
Overturned Requests:
• Decision rationale: According to the medical records provided for review, the patient has radicular symptomatology
and findings on examination and documented by previous electrodiagnostic studies as well as MRI. Her therapeutic
options appear to be limited by external issues restricting the use of analgesics and she has been described as reaching
maximal medical improvement. Her clinical picture qualifies her for the lumbar epidural procedure. Therefore the
request for the Right Lumbar ransforaminal Epidural Steroid Injection at L5-S1 under fluoroscopy is deemed to be
medically necessary and appropriate
55.
56. Functional Restoration Programs
Functional Restoration Programs be based on comprehensive evaluation of the patient's functional
capabilities and psychological overlay.
Functional Restoration Program. The MTUS guidelines page 49 recommends functional restoration
programs and indicate it may be considered medically
necessary when all criteria are met including (1) adequate and thorough evaluation has been made (2)
Previous methods of treating chronic pain have been unsuccessful (3) significant loss of ability to
function independently resulting from
the chronic pain; (4) not a candidate for surgery or other treatments would clearly be (5) The patient
exhibits motivation to change (6) Negative predictors of success above have been addressed.
Also, California Medical Treatment Utilization Schedule recommends that a Functional Restoration
Program is appropriate for patients who have not
responded to previous chronic pain treatments and are unlikely to show any significant clinical
improvement from further treatment.
California Medical Treatment Utilization Schedule recommends a functional restoration program for
patients that have had an adequate and thorough baseline evaluation to support functional improvement
throughout the program and documentation of willingness and a motivation to change
57. Common Errors
• Fails to provide any evidence that the patient has undergone a comprehensive psychological or
physical evaluation to determine the patient's appropriateness for a Functional Restoration Program.
• Documentation submitted for review does not provide evidence that the patient has exhausted all
lesser forms of conservative treatment and will not significantly improve as a result of further
conservative treatments.
• Does not clearly identify a duration of treatment.
• The appropriateness of that treatment cannot be established
• The clinical documentation as it is submitted does not contain any evidence of the patient's
motivation to change or a functional baseline assessment to assist in determining functional
improvements related to the program.
• The clinical documentation submitted for review does not provide evidence that treatment beyond
the recommended 20 sessions is necessary
• It is not clear whether the patient is a candidate for surgery or other treatment, whether he had
exhibited motivation to change, and whether negative predictors of success have been addressed.
• Request for six weeks of treatment in a functional restoration program is not supported as the patient
does not meet all of the criteria and the request for treatment for 6 weeks exceeds the guideline
recommendations
• Negative predictors of success have not been addressed
• There are no exceptional factors noted within the documentation to support extending treatment
beyond guideline recommendations.
58.
59. 96101 and 99354
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
·
ISSUE IN DISPUTE:
Provider seeking full remuneration 96101, Psychological Testing Per Hour, 99354 Prolonged service in the office or
other outpatient setting requiring direct patient contact beyond the usual service; first hour performed on 05/09/2014.
Claims Administrator $0.00 Reimbursement Rational based on “NCCI Edits.”
·
Pursuant Title 8 CCR Physician Fee Schedule 1/1/2014, § 9789.12.13 Correct Coding Initiative: (a) The National Correct
Coding Initiative Edits (“NCCI”) adopted by the CMS shall apply to payments for medical services under the Physician
Fee Schedule. Except where payment ground rules differ from the Medicare ground rules, claims administrators shall
apply the NCCI physician coding edits and medically unlikely edits to bills to determine appropriate payment. Claims
Administrators shall utilize the National Correct Coding Initiative Coding Policy Manual for Medicare Services. If a
billing is reduced or denied reimbursement because of application of the NCCI, the claims administrator must notify the
physician or qualified non-physician practitioner of the basis for the denial, including the fact that the determination was
made in accordance with the NCCI.
60. 96101 x 7 units, 99354 X 1 UNIT.
CMS 1500 form reflects 96101 x 7 units, 99354 X 1 UNIT.
CMS 1500 reflects multiple services, including 99205.
EOR reflects Provider reimbursed for 99204.
Based on the NCCI edits code pair exist between CPT 99205/99204 and 96101.
Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation
supports the use of the procedure code then the edit may be overridden.
Article 5.5.0. Rules For Medical Treatment Billing and Payment §9792.5.7. Requesting Independent Bill Review (b)(2)
The proper selection of an analogous code or formula based on a fee schedule adopted by the Administrative Director, or,
if applicable, a contract for reimbursement rates under Labor Code section 5307.11, unless the fee schedule or contract
allows for such analogous coding.
The correct modifier (-59) was not appended to the column 2 codes: 96118. As such, reimbursement is not indicated.
Page 59 of the Phsychological report indicates “15” minutes reviewing medical file.” Breakdown of total visit time –vs-
psychological testing, could not be abstracted from report. CPT 99204, reimbursed by the Claims Administrator, has a
time factor or 45 min.
Billed Prolonged Services Code, 99354 is a “per hour code” and is not factored into the visit time until, at the very least,
an additional 45 minutes have surpassed the time involved with the Evaluation and Management service.
·
Based on the aforementioned documentation and guidelines, additional reimbursement is not indicated for 96101 and
99354
63. The Rook
The Rook or slang, castle (because it looks like a castle) , is defined as, the
IBR process and fee schedule issues. The castle is a strong and powerful piece
and each player has two. The rook can move forward and backward or from
side to side and covers a wide range of the board. However, because of its
limited function, all players always look to see where the rook is, thus few
surprises, as it is more of a matter of fact piece. The IBR process is a powerful
tool and regardless of the $195.00 fee, it has to be used, because of the several
IBR decisions already posted, going to the IBR and knowing the results before
hand should be no surprise. However, mastering the rook is knowing how the
rook has been played in other games to achieve a wining game, i.e. sometimes
it addresses; authorization issues, PPO issues and usual and customary, making
those who read the IBR decisions a master of playing the rook, for winning
moves
65. Why One Is Right
"Lien claimant, Passages Malibu, seeks reconsideration and removal
from the Findings and Award, issued July 1, 2015,- in which a workers'
compensation administrative law judge (WCJ) ordered defendant
Liberty Mutual/Wausau, to pay lien claimant the sum of $272,533.26,
as the reasonable value of the services provided to applicant Bruno
Sabato, less credit for sums paid. Lien claimant contends the WCJ's
finding of the reasonable value of lien claimant's services is
not substantiated by the evidence, and requests that the Appeals Board
remove this matter to itself and find that it is entitled to payment of
$1,130,975.60. Lien claimant contends that there is no dispute as to its
entitlement for payment as defendant pre-authorized 300 days of
services at its residential treatment
facility."
66. ML104-95 Evaluation, 96101 and 96118 Psychological Testing
performed on Injured Worker 10/07/2014
ISSUE IN DISPUTE: Provider seeking remuneration for ML104-95 Evaluation, 96101
and 96118 Psychological Testing performed on Injured Worker 10/07/2014.
Claims Administrator reimbursed $0.00 of $6,331.45 with the following rational:
Claim denied and is currently in litigation.
May 29, 2014 Letter from Claims Admin Legal parties, addressed to the Provider
indicated the following: Defendants do not believe that the applicant is entitled to a
Psychiatric Panel at this time.
August 12, 2014 Letter to Provider from Claimants Attorney requesting PQM
Psychological Evaluation to include Causation and Apportionment.
Court Order, 07/17/2014, signed by Workers Compensation Administrative Law Judge
Granted the following: Applicant to go to PQME Eval w/ (Provider) to resolve psych
issues.
Provider is the PQME evaluator stated in the court order
68. 96118-59 and 9611-59
Claims Administrator denied codes indicating on the Explanation of Review Payment based on
individual pre-negotiated agreement for this specific service and Service exceeds agreed utilization
Letter dated 02/25/2015 from Utilization Review authorized 6 units Neuropsych Testing by TE for
insomnia nos. Service dates from 02/25/2015 through 03/25/2015
96119 -Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory
Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report,
administered by technician, per hour of technician time, face-to-face
Interpretation and report by the technician were not found for this review. Therefore, documentation does
not support billed code 96119 and reimbursementis not warranted.
CPT 96118 -Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler
Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time,
both face-to-face time administering tests to the patient and time interpreting these test results and
preparing the report
Report dated March 25, 2015 titled Neuropsychological Evaluation signed by Provider above, documents
a consultation with the injured worker as 1.5 hours and 7 hours of interpretation & report writing by the
neuropsychologist
69.
70. 22848, 63012, 63044, 63047, and
63048
ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 22848, 63012,
63044,
63047, and 63048
Claims Administrator denied code 22848 indicating on the Explanation of Review
Per CCI Edits, the value of this procedure is included in the value of the comprehensive
procedure
If modifier column shows 1 for pair codes, if an approved modifier is appended to the
column 2 code and documentation is submitted to support the billed service, then the
edit may be overridden.
As a pair code exists between billed code 22848 and reimbursed code 27280, provider
did not apply a proper modifier to 22848 on the CMS 1500 form. Therefore,
reimbursement of 22848 is not warranted.
71. 22848, 63012, 63044, 63047, and
63048
CHAP8-CPTcodes60000-69999_final10312013.doc; NATIONAL CORRECT CODING
INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES Revision Date: 1/1/2014C. Nervous System: 18. A
laminectomy includes excision of all the posterior
vertebral components, and a laminotomy includes partial excision of posterior vertebral components. Since a laminectomy is a
more extensive procedure than a laminotomy, a laminotomy code should not be reported with a laminectomy code for the same
vertebra
Provider s report documents Next, decompressive laminectomies/facetectomies were performed from T12-S1. From T12-L3
laminotomies/laminectomies were performed
Reimbursement of codes 63047 and 63048 is warranted.
Reimbursement of 63044 is not warranted.
CPT 63012 was denied by Claims Administrator as �The submitted documentation does not support the service being billed
for. We will re-evaluate this upon receipt of clarifying information
63012 - Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and
nerve roots for spondylolisthesis, lumbar (Gill type procedure)
Provider s documentation describes At L4-5, a Gill-type procedure was performed
Reimbursement of 63012 is warranted.
72.
73. 63081, 63082-59 X 3, 22851-59 X 3, 69990-59,
and 76001-59
SSUE IN DISPUTE: Provider is dissatisfied with reimbursement of codes 63081, 63082 -
59 X 3, 22851-59 X 3, 69990-59, and 76001-59
Provider denied codes indicating on the Explanation of Review The charge for this
procedure was not paid since the value of this procedure is included/bundled within The
value of another procedure performed
Provider billed code 69990-59 along with reimbursed billed code 22554. Per NCCI Edit of
the pair code between these two states they are never to be billed together and a modifier is
not allowed to override the edit. As such, reimbursement of 69990 is not warranted.
Claims Administrator also denied code 76001-59, Fluoroscopy, physician or other
qualified health care professional time more than 1 hour, assisting a nonradiologic
physician or other qualified health care professional (eg, nephrostolithotomy, ERCP,
bronchoscopy, transbronchial biopsy)
Providers report submitted does not document 76001 and therefore, reimbursement is not
warranted for 76001.
74. 63081, 63082-59 X 3, 22851-59 X 3,
69990-59, and 76001-59
Provider also billed 3 units of 22851-59,Application of intervertebral biomechanical device(s) (eg,
synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to
code for primary procedure)which is documented in the providers report.
Reimbursement of 22851 x 3 is warranted.
Provider also billed 63081, Vertebral corpectomy (vertebral body resection), partial or complete, anterior
approach with decompression of spinal cord and/or nerve root(s); cervical, single segment
Providers report documents A partial corpectomy had to be carried out before we were able to remove the
posterior osteophyte and decompress the spinal cord because of the very narrow disc space
Reimbursement of 63081 is warranted.
Provider documents �The same happened at C4-5 as well where partial corpectomy had to be carried
out as well�which supports billed code 63802, Vertebral corpectomy (vertebral body resection), partial
or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each
additional segment (List separately in
addition to code for primary procedure) for 1 unit.
•
75.
76. CPT 97750,
ANALYSIS AND FINDING
Based on review of the case file the following is noted: ISSUE IN DISPUTE: Provider is dissatisfied
with denial of CPT 97750, Physical
performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15
minutes
EOR does not indicate 97750 as unauthorized but does state No separate payment was made because the
value of the service is included within the value of another service performed on the same day
EOR s received only show CPT code 97750 billed along with CMS 1500 form billing only 97750.
Provider s report submitted documents 2 hours spent face to face and 60 minutes of report preparation
Opportunity to Dispute sent to Claims Administrator 08/12/2015; response not yet received
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for
97750 x12
Provider states a 10% PPO discount is to be applied to reimbursement
77.
78. 97670 “Functional Capacity Evaluation ” No Value
99499 at Customary Charges $1,687.50 /2nd
$2,375.00
Claims Administrator denied code indicating on the Explanation of Review “The Official Medical Fee
Schedule does not list this code(97670). No payment is being made at this time. Please resubmit your
claim with the OMFS codes that best describe the service(s) provided and your supporting
documentation”
Report Entitled “Functional Capacity Evaluation” reflects date of service 1/19/2015 OMFS allows for
Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the
value assigned to a comparable procedure or analogous code. The comparable procedure or analogous
code should reflect similar amount of resources, such as practice expense, time, complexity, expertise,
etc. as required for the procedure performed.”A code used in Functional Capacity Evaluation has been
99499.
There is no allowance or comparable code listed under the OMFS for service billed with procedure code
99499 or, more specifically, a Functional Capacity Evaluation;
Initial payments was zero allowed order for payments of billed charges in the amount of $1,687.50.
The correct billing code for a Functional Capacity Evaluation, 99499
79. 97670 “Functional Capacity Evaluation ” No Value 99499 at
Customary Charges $1,687.50 /2nd $2,375.00
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider dissatisfied with reimbursement of code 97799-86
Based on review of the Physician’s Initial Evaluation, procedure code 97799-86 is substantiated as the Provider
documented services performed and Provider’s Usual and Customary charge.
The Physician Evaluation details the injured worker’s medical history, current medications, physical examination
including functional strength, range of motion, function movement and lifting, dynamic posture and stabilization,
psychological evaluation, treatment plan and a formal request for authorization, a thorough evaluation was performed on
this injured worker
Claims Administrator based its reimbursement of 97799 86 on97670. The OMFS does not list an allowance for 97799 or
97670; these are described as “By Report” codes.
Documents reviewed included the Request for Authorization of Medical Treatment for an Initial Interdisciplinary
Evaluation documenting Provider’s cost at $2500.00.
Utilization Review Decision letter documented: Approved Initial Evaluation from 10/30/2013 –11/30/2013 Per the
supplied PPO contract, covered services billed with a procedure code for which there is no assigned value, Provider shall
be reimbursed at 95% of Eligible billed charge $ 2375.00
80. ANALYSIS AND FINDING
Based on review of the case file the following is noted: ·
ISSUE IN DISPUTE: Provider dissatisfied with reimbursement of code 97799-30·
Provider was reimbursed $471.81and is seeking additional reimbursement of $923.13.·
Claims Administrator sent a partial payment in the amount of $471.81 indicating on the Explanation of Review:
“The charge exceeds the official medical Fee Schedule allowance. The charge has been adjusted to the
scheduled allowance.” and “The Fee Schedule does not include a value for the procedure code billed. An
allowance has been made which is based on charges for similar/comparable services. Reimbursement is based
on the applicable reimbursement fee schedule.”
Claims Administrator does not state which code the 97799-30 is based on. ·
Included in this review is the Authorization Request –F.C.E. as a Panel QME, dated 4/8/2014 from the Provider.
The Request shows the CPT Request with Fee’s as 97799-30, Functional Capacity Evaluation/Unlisted Code, in
the amount $1395.00.
·
Claims Administrator sent Approved notification for Functional Capacity Evaluation dated April 17, 2014.
Instructions included “Services will be paid pursuant to the Official Medical Fee Schedule or an appropriate
PPO Contract” and the Authorization will expire in 60 Days
.
97799-30
81. 97799-30
Physician’s Functional Capacity Evaluation report documents “Approximately 5 hours and 40 minutes of physical
testing, report preparation, research, calculations and editing were performed in the completion of this Functional
Capacity Evaluation.” Provider also states: “Completion of the intake forms, health-screening questionnaire, job demand
questionnaire, the history, interview and eMTAP required reading and writing, while sitting and took approximately 50
minutes to complete” as well as “The patient is slightly restricted upon standing for 90 minutes during the functional
capacity evaluation.”
·
The Provider documents the numerous tests performed on this patient including strength test, sitting and standing
tolerance, aerobic step test, hand functional tests, manual muscle testing of the upper and lower extremity, tendon
reflexes, abnormal sensation, lifting capacity and carrying test, pushing and pulling, activities of daily living, fine motor
dexterity, cool down and activity log, functional capacity assessment and the Physician’s Permanent and
Stationary Report.
·
CPT code 97799 is an unlisted code the Provider billed at $1395.00. Claims Administrator reimbursed a partial payment
of $ 471.81 but failed to report what this figure was based on. Therefore, CPT code 97750, Physical Performance Test or
Measurement (egMusculoskeletal, Functional Capacity) with written report, each 15 minutes best describes the procedure
demonstrated and will replace the 97799-30 billed by the Provider.
·
CPT 97750 is listed on the Official Medical Fee Schedule at $38.34/unit and the provider spent a total of 340 minutes or
23 units. 38.34 x 23 = 881.82, this will be the appropriate Official Medical Fee to use on this review
82.
83. OUTPATIENT FUNCTIONAL CAPACITY
EVALUATION (FCE):Overturned
Claims Administrator guideline: Decision based
on MTUS Chronic Pain Treatment Guidelines.
MAXIMUS guideline: Decision based on MTUS
ACOEM Chapter 5 Cornerstones of Disability
Prevention and Management Page(s): 89-92.
Decision based on Non-MTUS Citation Official
Disability Guidelines (ODG) Chapter Fitness for
Duty Chapter, FCE.
84. ACOEM guidelines
Decision rationale: ACOEM guidelines indicate there is a functional assessment tool available
and that is a Functional Capacity Evaluation, however, it does not address the criteria. As such,
secondary guidelines were sought. Official Disability Guidelines indicates that a Functional
Capacity Evaluation is appropriate when a worker has had prior unsuccessful attempts to return
to work, has conflicting medical reports, the patient had an injury that required a detailed
exploration of a workers abilities, a worker is close to maximum medical improvement and/or
additional or secondary conditions have been clarified. However, the evaluation should not be
performed if the main purpose is to determine a worker's effort or compliance or the worker has
returned to work and an ergonomic assessment has not been arranged. The clinical
documentation submitted for review indicated the patient had prior unsuccessful attempts to
Return to work and was close to maximum medical improvement. Given the above, the request
for a Functional Capacity Evaluation is medically necessary
85. EPIDURAL INJECTION
The criteria for the use of epidural steroid injections are as follows:
1) Radiculopathy must be documented by physical examination and corroborated by imaging studies
and/orelectrodiagnostic testing.
2) Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs and muscle
relaxants).3) Injections should be performed using fluoroscopy (live x-ray) for guidance.
4) If used for diagnostic purposes, a maximum of two injections should be performed. A second block is
notrecommended if there is inadequate response to the first block. Diagnostic blocks should be at an
interval of at least one to two weeks between injections.
5) No more than two nerve root levels should be injected using transforaminal blocks.
6) No more than one interlaminar level should be injected at one session.
7) In the therapeutic phase, repeat blocks should be based on continued objective documented pain and
functional improvement, including at least 50% pain relief with associated reduction of medication use
for six to eight weeks, with a general recommendation of no more than 4 blocks per region per year.
(Manchikanti,2003) (CMS, 2004) (Boswell, 2007) 8) Current research does not support a "series-of-
three" injections in either the diagnostic or therapeutic phase.
86. Elements:
• unresponsiveness to conservative treatment.
• imaging studies
• clear clinical signs of radiculopathy and non-corroborative findings on imaging,
Additional Injections:
• Objective Functional Improvement from prior injections The ODG identifies documentation of at least 50-70%
pain relief for six to eight weeks, with a general recommendation of no more than four blocks per region per year, as well
as decreased need for pain medications, and functional response as criteria necessary to support the medical necessity of
additional epidural steroid injections.
Common Mistakes
• lack of documentation indicating the injured worker had radiating pain with the straight leg raise.•
• lack of documentation of failure of conservative care.
• failed to indicate the laterality, as well as the level for the injection
• no indication for failed conservative trial for diagnoses of cervicalgia and cervical
• no imaging studies provided for review.
• no documentation of unresponsiveness to conservative treatment.
• no more than 2 joint levels are injected in one session is recommended
• no documentation of at least 50-70% pain relief for six to eight weeks following previous injection
Overturned Requests:
• Decision rationale: According to the medical records provided for review, the patient has radicular symptomatology
and findings on examination and documented by previous electrodiagnostic studies as well as MRI. Her therapeutic
options appear to be limited by external issues restricting the use of analgesics and she has been described as reaching
maximal medical improvement. Her clinical picture qualifies her for the lumbar epidural procedure. Therefore the
request for the Right Lumbar ransforaminal Epidural Steroid Injection at L5-S1 under fluoroscopy is deemed to be
medically necessary and appropriate
87.
88. Functional Restoration Programs
Functional Restoration Programs be based on comprehensive evaluation of the patient's functional
capabilities and psychological overlay.
Functional Restoration Program. The MTUS guidelines page 49 recommends functional restoration
programs and indicate it may be considered medically
necessary when all criteria are met including (1) adequate and thorough evaluation has been made (2)
Previous methods of treating chronic pain have been unsuccessful (3) significant loss of ability to
function independently resulting from
the chronic pain; (4) not a candidate for surgery or other treatments would clearly be (5) The patient
exhibits motivation to change (6) Negative predictors of success above have been addressed.
Also, California Medical Treatment Utilization Schedule recommends that a Functional Restoration
Program is appropriate for patients who have not
responded to previous chronic pain treatments and are unlikely to show any significant clinical
improvement from further treatment.
California Medical Treatment Utilization Schedule recommends a functional restoration program for
patients that have had an adequate and thorough baseline evaluation to support functional improvement
throughout the program and documentation of willingness and a motivation to change
89. Common Errors
• Fails to provide any evidence that the patient has undergone a comprehensive psychological or
physical evaluation to determine the patient's appropriateness for a Functional Restoration Program.
• Documentation submitted for review does not provide evidence that the patient has exhausted all
lesser forms of conservative treatment and will not significantly improve as a result of further
conservative treatments.
• Does not clearly identify a duration of treatment.
• The appropriateness of that treatment cannot be established
• The clinical documentation as it is submitted does not contain any evidence of the patient's
motivation to change or a functional baseline assessment to assist in determining functional
improvements related to the program.
• The clinical documentation submitted for review does not provide evidence that treatment beyond
the recommended 20 sessions is necessary
• It is not clear whether the patient is a candidate for surgery or other treatment, whether he had
exhibited motivation to change, and whether negative predictors of success have been addressed.
• Request for six weeks of treatment in a functional restoration program is not supported as the patient
does not meet all of the criteria and the request for treatment for 6 weeks exceeds the guideline
recommendations
• Negative predictors of success have not been addressed
• There are no exceptional factors noted within the documentation to support extending treatment
beyond guideline recommendations.
90.
91. 96101 and 99354
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
·
ISSUE IN DISPUTE:
Provider seeking full remuneration 96101, Psychological Testing Per Hour, 99354 Prolonged service in the office or
other outpatient setting requiring direct patient contact beyond the usual service; first hour performed on 05/09/2014.
Claims Administrator $0.00 Reimbursement Rational based on “NCCI Edits.”
·
Pursuant Title 8 CCR Physician Fee Schedule 1/1/2014, § 9789.12.13 Correct Coding Initiative: (a) The National Correct
Coding Initiative Edits (“NCCI”) adopted by the CMS shall apply to payments for medical services under the Physician
Fee Schedule. Except where payment ground rules differ from the Medicare ground rules, claims administrators shall
apply the NCCI physician coding edits and medically unlikely edits to bills to determine appropriate payment. Claims
Administrators shall utilize the National Correct Coding Initiative Coding Policy Manual for Medicare Services. If a
billing is reduced or denied reimbursement because of application of the NCCI, the claims administrator must notify the
physician or qualified non-physician practitioner of the basis for the denial, including the fact that the determination was
made in accordance with the NCCI.
92. 96101 x 7 units, 99354 X 1 UNIT.
CMS 1500 form reflects 96101 x 7 units, 99354 X 1 UNIT.
CMS 1500 reflects multiple services, including 99205.
EOR reflects Provider reimbursed for 99204.
Based on the NCCI edits code pair exist between CPT 99205/99204 and 96101.
Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation
supports the use of the procedure code then the edit may be overridden.
Article 5.5.0. Rules For Medical Treatment Billing and Payment §9792.5.7. Requesting Independent Bill Review (b)(2)
The proper selection of an analogous code or formula based on a fee schedule adopted by the Administrative Director, or,
if applicable, a contract for reimbursement rates under Labor Code section 5307.11, unless the fee schedule or contract
allows for such analogous coding.
The correct modifier (-59) was not appended to the column 2 codes: 96118. As such, reimbursement is not indicated.
Page 59 of the Phsychological report indicates “15” minutes reviewing medical file.” Breakdown of total visit time –vs-
psychological testing, could not be abstracted from report. CPT 99204, reimbursed by the Claims Administrator, has a
time factor or 45 min.
Billed Prolonged Services Code, 99354 is a “per hour code” and is not factored into the visit time until, at the very least,
an additional 45 minutes have surpassed the time involved with the Evaluation and Management service.
·
Based on the aforementioned documentation and guidelines, additional reimbursement is not indicated for 96101 and
99354