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.