See §127.755 of the Pennsylvania Workers Compensation Code 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.

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.

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 Improper Payments Elimination and Recovery Act (H.R. 3393) 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.

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.

Robin Perkins was struck by a car while she was walking in a grocery store parking lot. She was insured by State Farm (her motor vehicle insurance policy covered her even though she was a pedestrian) who refused to pay for her chiropractic care based on a peer review performed by another chiropractor well known to do this type of work.

The Court said, and it is correct, that there has been conflicting results in Pennsylvania as to whether Act 6 provides the exclusive remedy for the patient’s claim against State Farm, or whether she can bring a bad faith claim under the Bad Faith Statute (Section 8371), which provides for punitive damages.

Although the Pennsylvania Supreme Court has not weighed in yet to resolve the conflict, the U.S. District Court, following the Schwartz opinion in the Third Circuit, ruled that such care is in fact dependant to determine whether the patient can bring a bad faith action. In this case, the patient argued that the peer reviewer does substantial work for State Farm and therefore has a financial interest in providing a biased peer review. Further, the patient alleged that the peer reviewer repeatedly gave negative peer reviews to State Farm in order to maintain its relationship with State Farm. These allegations are not part of what Act 6 covers and therefore the patient could go forward with her bad faith claim.

A federal jury in Philadelphia on March 26, 2009 found in favor of State Farm Mutual Automobile Insurance company against Dr. Arnold Lincow, two other osteopaths, and two chiropractors, as well as four corporate entities. The jury assessed $4,049,741.00 against each of the defendants for violation of two parts of RICO, as well as statutory and common law fraud. The jury also assessed punitive damages against Dr. Lincow in the amount of $5,000,000.00 (five million dollars), and $600,000.00 (six thousand dollars) against each of the other defendants.

State Farm argued that from 2000 until the present Dr. Lincow perpetrated a scheme with fellow defendants to exhaust all available benefits under a patient’s motor vehicle medical insurance. The jury agreed with State Farm that Dr. Lincow and his co-defendants performed inappropriate and medically unnecessary testing and treatment, created standardized treatment plans and reports, billed for services that were never received or more costly than actually rendered, submitted fake billing information and fake supporting documentation , employed untrained and unlicensed personnel to provide treatment as if it were provided by licensed and trained personnel, misrepresented the identity of the treating physician, and used a physician to incorrectly diagnose testing as positive (EMG and nerve conduction tests) for which he received a kickback.

The trial lasted three weeks and various attorneys associated with Dr. Lincow had their files subpoenaed to provide evidence as to the RICO scheme. The counterclaims filed by the defendants in the case were rejected by the jury. The defendants have 30 days from March 26, 2009 to file an appeal.

My office has represented chiropractors throughout the Commonwealth in obtaining money from insurance companies who will not pay for care rendered to motor vehicle accident victims. Many of these doctors have allowed large sums of money to accumulate for non-payment for motor vehicle accident victims for various reasons. Some do not realize that they can sue the insurance carrier for recovery. Some think they will sue the carrier themselves in small claims court, but never get around to it. Whatever the reason, this is money which should be in the doctor’s bank account and not the insurance carriers.

The amount of work on your part is relatively painless. A copy of any peer review as well as a statement showing the total amount of money due and owing can be faxed or emailed to my office to get the process started. We then place the case in suit after you send us the filing fee, which is typically around $100.00. The majority of these cases are settled without your having to appear in Court.

A federal judge has predicted that the Pennsylvania Supreme Court will eventually rule that an insurance carrier can discontinue medical payments if the insured does not submit to a reasonable medical exam.  By way of background, this case involved an insured with Allstate who refused to undergo an independent medical exam when requested to do so by Allstate.  The insured refused to go to the IME because Allstate had not obtained a Court Order requiring the insured to do so, even though there was a provision in the Allstate policy allowing Allstate to require the insured to submit to an IME or face discontinuance of coverage.  The federal judge relied on a Pennsylvania Superior Court case that stated when a policy for car insurance contains language which explicitly states the carrier can compel an insured to attend an IME, such a provision is enforceable without the need for the carrier to obtain a court order.  Many carriers, e.g. Nationwide, are performing a peer review and buttressing their position to discontinue payments with an IME.