The purpose of this post is to help assist those with questions they have concerning their business or medical practice. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. We hope to have this blog shed a light on many common questions.
An Assignment of Benefits (AOB) in the world of No-Fault Law, also known as Personal Injury Protection (PIP), is critical in order for a medical provider to be reimbursed by a PIP insurance carrier. Indeed, a contractual relationship exists between the patient (insured) and the carrier (insurer), but no such relationship exists between the carrier and the medical provider. The AOB is what transfers, or “assigns,” the patient’s rights to receive PIP benefits to the medical provider. Without it, the medical provider would have no legal right to claim reimbursement from the carrier.
So, why and how is it that very often claims are allowed to go forward when there is no signed AOB, or the AOB that is presented is sufficiently defective as to render it not truly an effective legal instrument to transfer rights, or it is executed by someone who clearly would not have the right to effectuate such an assignment. These instances often present themselves in the context of Emergency Room (ER) treatment, where the niceties of signing intake forms and other consents do not exist because of the traumatic nature of the events, injuries and treatment. The atmosphere by its very nature is emergent and therefore warrants consideration beyond the standard practices found in by-choice, pre-scheduled doctor visits and procedures.
In these situations, PIP arbitrators, known as Dispute Resolution Professionals (DRPs), at times do allow the claims to go forward when there is no AOB, or it is signed by hospital personnel, or it is signed by a stranger to the patient’s policy, or it is somehow otherwise defective. They do this in recognition of fundamental fairness and equity, because there is no dispute as to the carrier’s liability. There is only the defect of the nonexistent or defective AOB. Though it is rarely recognized as such, the legal conclusion being drawn by these DRP’s is that an implied AOB exists.
In effect, even though the patient has not signed an AOB, which would expressly and unequivocally transfer to the ER doctors and hospital the right to recover PIP benefits, the circumstances dictate that the patient implies an assignment when they accept treatment under the circumstances. Indeed, hospitals are required by law to treat anyone who comes into the ER, regardless of their ability to pay and regardless of insurance. Therefore, it seems only fair that in the circumstances of ER treatment, medical providers should be able to pursue PIP carriers in arbitration regardless of a written AOB, because an assignment is clearly implied from the circumstances.
For more information on AOB, please read our blog:
Why I an Assignment of Benefits So Important?
We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $185,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.
Learn More About Callagy Law Here:
In accordance with newly adopted Personal Injury Protection Benefits; Medical Protocols; Diagnostic Tests rules, Consolidated Services Group has been chosen by the Group of insurance carriers below to administer their Decision Point Review plans. Under these newly adopted rules, it is required to provide informational materials available via the World Wide Web.
New Jersey Department of Banking & Insurance
Notice to Providers treating NJ insured patients injured as a result of an auto accident:
In accordance with Order No.: A16-101, effective February 9, 2016, the revised Attending Provider Treatment Plan form shall be used by all Providers to submit Decision Point Review and Pre-certification Requests.
To obtain a copy of this form, click on the following link - http://www.state.nj.us/dobi/pipinfo/aptp_ver160310.pdf. NO OTHER FORMS FOR THIS PURPOSE ARE PERMITTED.
Visit the NJ Department of Banking & Insurance website at http://www.nj.gov/dobi/aicrapg.htm to obtain a copy of the complete Order No.: A16-101 and other valuable resource materials and information.