The Commonwealth Court of Pennsylvania recently issued an important decision in the case of Houston v. SEPTA

, No. 1445 C.D. 2010.  The issue in this case was whether SEPTA, as a self-insured transportation authority, was required to comply with the cost containment provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL, part of which is known as Act 6).  After disposing of some preliminary issues dealing with standing and class actions certification, the Court held that SEPTA was in fact required to comply with the cost containment provisions of Act 6.

In practical terms, this decision is a victory for those injured in an accident involving a SEPTA bus.  SEPTA, as a self-insured entity, provides $5000 in medical visits for injured bus passengers not having their own insurance who were involved in an accident.  Prior to this ruling, SEPTA had paid bills in the full amount invoiced by providers until the $5000 limit was reached.  Under Act 6, providers are reimbursed at a reduced rate for services, equal to 110% of the reimbursement for Medicare.  This amount is typically 60-70% what a provider charges to a cash basis patient.  Since SEPTA must now pay the MVFRL rates, individuals injured in a SEPTA bus accident will be able to receive more care from their different medical provider before becoming personally responsible for payments, because there is less chance any one provider can alone exhaust the $5000 available from SEPTA.  Providers should be aware that these payments are made on first-come, first-serve basis.  Therefore, bills should be promptly submitted to ensure payment.

The Environmental Protection Agency has issued a new regulation entitled the “Renovation and Repainting Rule”. The new RRP Rule was written to deal with hazards created by renovation, repair and painting that disrupts lead-based paint in “targetted housing” and “child occupied facilties”. New requirements are written into the rule for training renovators, certifying how the lead-paint was disturbed, and dust minimization and work practices. The rule applies to renovators, electricians, HVAC specialists, plumbers, painters, electricians, drywall intallers, insulation isntallers, siding contractors and many other trademen who disrupt more than six square feet of lead paint. The rule also appplies to landlords, builders, and education service providers. Target housing  are pre-1978 homes, unless a child under six is present in the home and thus would be included in the definition. Child occupied facilities are pre-1978 buildings visited regulalrly by the same child under six, or at least two days per week, with each visit lasting at least three hours. Child occupied facilities include day care centers, preschools and kindergarten. Specific information regarding the renovation must be distributed before work is started by signs being posted and pamphlets mailed. The rule does not cover “rapairs and maintenance activities” which cover less than six square feet of interior space or twenty feet of exterior space. Window replacement, however, is not exempt regardless of the square footage involved. Failure to follow the rule could impose a fine of $37,500.00 per violation, civil liability, and potential litigation.

In the second installment of our informational video series, we at Jules Zacher, P.C. are delighted to bring you a new video covering the differences between Limited and Full Tort Auto Insurance coverage.  We hope you find this video helpful.

Today’s Quick Tip covers Workers Compensation. Did you know that under certain circumstances an injured employee has the right to visit any type of medical provider from day 1 of their treatment instead of visiting a panel doctor? Unless the employee receives and acknowledges written notice from their employer that they must visit an employer-designated provider, the employee is free to treat with a provider immediately.

See for the full section of the code.  Be sure browse the website for other helpful tips on subjects like motor vehicle accidents, premises liability (slip and fall) accidents, and more.

A chiropractor recently sent a file to this office regarding a patient involved in an automobile accident.  The insurance company had a peer review performed for the care rendered in which the peer reviewer submitted the following opinions:  The patient had reached maximum medical improvement (MMI) one month after the trauma of the accident.  The reviewer reached this conclusion because the subjective complaint of continued low back pain at that point was the same as it was on the first visit.

My argument to the judge and the defense attorney is that it would be unusual if the patient did not

experience low back pain one month post-accident.  Aside from the ridiculousness of the insurance company’s position, what is most important is that the provider in question was not aware that he had four years from the date of the accident, or from the last payment by the insurance company (whichever date is later) to initiate a lawsuit to get his money back.  Not knowing this fact, the chiropractor had essentially written off the monies as a loss.

In this regard, it should be noted that my office does this type of work on a contingent basis.  This means that if there is no recovery for the provider, there is no fee except the initial court filing fee.  (In Philadelphia Municipal Court, where these cases are most often filed, the filing fee ranges between $56 and $132.)  If you are having trouble getting paid by an insurance company, contact my office for a consultation.

Like most auto insurance law, the choice between Full and Limited Tort insurance coverage can be a confusing one.  But, the implications are great.

With Full Tort coverage, a driver who has been in an accident is able to recover monies through litigation for both economic damages (i.e. property damage, lost wages, etc.) and

pain and suffering.  This means that should the driver be injured in an accident through someone else’s negligence, they can potentially obtain a recovery representing the full extent of the damage done in the accident.  This type of coverage is especially helpful when an auto accident causes long-term chronic pain.

Limited Tort coverage is a bit more, well, limited.  In exchange for lower monthly premiums, a driver with Limited Tort insurance coverage gives up the right to sue for pain and suffering.  This means that a driver can only recover economic damages like damage to the vehicle, medical expenses immediately resulting from the accident, or lost wages.

There are, however, some exceptions that allow an accident victim to overcome the restrictions of Limited Tort coverage.  For instance, the Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL) allows drivers with Limited Tort policies to sue for pain and suffering if they have sustained a “serious injury” resulting in “death, serious impairment of body function or permanent serious disfigurement.” (75 Pa.C.S.A. § 1702

)  In practice, this exception has generally not included soft-tissue injuries like sprains or even most bone or head injuries.

In recent weeks, however, there has been some indication that courts are willing to consider awarding monies for pain and suffering to individuals with Limited Tort coverage whose injuries do not, at face value, appear to meet the “serious injury” threshold described in the statute.  In Harlan v. Pennsylvania State Police, et al., (PICS Case No. 10-1506 (C.P. Pa. [Lawrence County] March 4, 2010)

, a judge ruled that a Limited Tort plaintiff’s case should not be dismissed, even though he did not suffer the types of injuries usually necessary to overcome the restrictions on Limited Tort.  According to Pennsylvania Law Weekly

, the plaintiff “suffered injuries to his left arm, left shoulder, left wrist, neck, back, and head.”  Months after the accident, the plaintiff underwent three surgeries, missing a total of five months of work.  He continued to experience pain and loss of feeling on his left side, and as a result was limited in his ability to perform “daily tasks including driving and mowing the lawn.”  The court found that because the plaintiff’s household and recreational activities have been altered for the foreseeable future, it is up to a jury to decide whether or not this constitutes a “serious injury” under the MVFRL. (Pennsylvania Law Weekly

, March 30, 2010, p. 17-18).

Because the potential for a major financial recovery is often diminished under the MVFRL, many attorneys are unwilling to pursue Limited Tort cases.  Jules Zacher, Esquire, however does

accept Limited Tort cases, provided they have legal merit.  If you have been injured in an auto accident, please visit the page of this website, and fill out a questionnaire.

President Obama recently announced plans to crack down on cases of Medicare and Medicaid fraud. At a recent health care rally in St. Charles, MO, the President announced his support for a bill directing federal auditors to uncover fraudulent claims that are estimated to cost taxpayers $100 billion per year. The new legislation has significant implications for medical providers.

At the March 10, 2010 rally, Obama emphasized the gravity of the initiative. “The health care system has billions of dollars that should go to patient care,” Obama said, “and they’re lost each and every year to fraud, to abuse, to massive subsidies that line the pockets of the insurance industry.”

If passed, the would require government agencies to hire auditors to investigate fraudulent claims. Administration officials have said that pilot programs run in three states between 2005 and 2008 recovered $900 million worth of fraudulent or incorrect claims.

But how can medical providers be sure they’re on the right side of these rules?

We at Jules Zacher, P.C. are pleased to announce that in an effort to provide fuller service to chiropractors, we have recently begun working with Jason Martin, an attorney with his own firm who has special expertise in health care law, to help medical providers navigate federal regulations on payment. Jason’s advice can help you avoid a costly and unpleasant audit in the face of complex regulations.

Make sure you and your practice aren’t on the wrong side of these regulations; contact Jules Zacher, P.C. today.

Three pamphlets containing useful information regarding the legal implications of a variety of subjects are now available for download as PDF files.  The pamphlets cover some of Jules Zacher’s areas of practice, and provide helpful tips and explanations of your legal rights.  We suggest you print them out and keep them handy in case of emergency.

We at Jules Zacher P.C. are pleased to introduce a new feature to www.juleszacher.com, namely, informational videos concerning legal issues that affect the practices of medical providers.

The first such video, entitled “Getting Providers Paid” covers some of the basics of Act 6, and details some of the options available to providers who have been denied payment by insurance companies.

Please visit the following link to view the video:

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Chiropractors from across the Commonwealth are reporting a disturbing trend. Insurance companies are refusing to pay chiropractors for radiological procedures in cases governed by the Motor Vehicle Financial Responsibility Law (Act 6). They claim that since Medicare does not pay for radiological procedures by chiropractors, Act 6 does not require them to do so.

While this issue has not been the subject of a binding appellate decision in Pennsylvania, the better view is that Section 69.21 of the Insurance Code requires payment for necessary procedures within a provider’s scope of practice even if he would not be paid by Medicare. If an insurance company is refusing to pay you for radiological procedures, you do not need to accept that determination. Contact my office for information on how you can protect your rights.