New Jersey - Volume VII, Number 6 - June, 1998
New Jersey - Volume VII, Number 6 - June, 1998
OFFICE SURGICAL AND ANESTHESIA STANDARDS ADOPTED
After more than a year since being proposed, the Boards of Medical Examiners’ surgical and anesthesia standards for the office setting finally have been adopted. Published June 15, 1998, the regulations are substantially the same as the proposal, the most significant change being removal of the prohibition on office surgery on ASA Class III patients when using only conscious sedation. The equipment and safety systems required by the rule must be purchased and installed no later than December 15, 1998. The remainder of the rule is effective upon its publication.
HMO CLAIMS PAYMENTS REGULATIONS PROPOSED
Attempting to clarify what is already statutorily required, and to prevent unnecessary delaying payment of claims, the Department of Health and Senior Services ("DHSS") has proposed regulations for HMOs to follow in determining claims payment issues. The regulations interpret "clean claim" and "contested claim," specify the minimum information the HMO must provide in explaining why a claim is contested or denied, and clarify the interest penalty on late payments. An HMO cannot contest a claim for lack of information that has no factual impact on the HMO’s ability to adjudicate the claim and the HMO’s use of an intermediary to process claims does not lessen the HMO’s obligations to comply with timeframes. Once adopted, the regulations will be immediately applicable, regardless of what the existing HMO contract states.
PROSECUTION GUIDELINES PUBLISHED FOR CLAIMS FRAUD ACT
The long-promised prosecution guidelines have been released and they do little to assuage the concerns of health lawyers that the Attorney General is looking to make the prosecution of health care fraud the touchstone of his administration. Indeed, the guidelines clearly establish the Attorney General as the Healthcare Claims Fraud Prosecution Czar and require that all handling of such cases (criminal or otherwise) be strictly coordinated through him. One can be assured that there will be aggressive and very public prosecution in this area. More will follow on this issue as the developments emerge.
PIP MANAGED CARE LAW ENACTED
On May 19, 1998, Governor Whitman signed into law the "Automobile Insurance Cost Reduction Act," an act which will have significant impact on personal injury protection (PIP) benefits and access to the courts for individuals injured in auto accidents. This new law will affect the insured’s election of automobile insurance coverage and his or her right to sue for non-economic damages. It also mandates the promulgation of regulations setting forth the basic medical benefits for which the insurer may require pre-certification before treatment and permits either party to a PIP dispute to refer the matter to a medical "peer-review organization."