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Larry E. Scienski Wins PIP Case with Rare Recovery of Fees and Costs for Allstate

Larry E. Scienski Wins PIP Case with Rare Recovery of Fees and Costs for Allstate

Larry E. Scienski handled a matter which originated as a medical necessity and UCR claim for surgical services. Allstate was required to pay for a surgery at 100% of a UCR determination, due to the provider improperly billing by not appending the necessary modifiers to the surgical codes submitted for reimbursement. After payment of the surgical service, a second provider submitted a demand for reimbursement as the co-surgeon in the same procedure. Representing Allstate, Larry sought reimbursement of the overpaid amount which was the difference between 100% of the surgical fee and 62.5% of the surgical fee payable to a co-surgeon. Despite this, the provider refused to reimburse the carrier for the overpayment.

Larry added the medical provider as a Co-Respondent to the Co-Surgeon’s demand. Upon rendering of the award, the DRP agreed with the carrier that this medical provider incorrectly billed the procedure at 100% and was required to reimburse the carrier the overpaid amount of $15,562.50. In addition, as a result of forcing the carrier to plead an action against them for reimbursement, the DRP also awarded $1300 in fees, $225 in costs, as well as accrued interest in the amount of $443.21. This is rarely achieved in PIP arbitration.