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Daniel R. Lagana Successfully Defends Allstate’s New Internal Appeals Process

Daniel R. Lagana Successfully Defends Allstate’s New Internal Appeals Process

Daniel R. Lagana successfully defended Allstate New Jersey Insurance Company’s new internal appeals process in a Forthright Arbitration proceeding recently.  The dispute arose out of an MRI study performed on October 22, 2016.  Allstate had issued payment for the study pursuant to the Fee Schedule, but applied a 50% pre-certification penalty, as well as a 30% out-of-network penalty.  On July 13, 2017, the provider filed a Post-Service Appeal pursuant to Allstate’s new Decision Point Review Plan.  The appeal challenged only the application of the 50% pre-certification penalty.  Allstate reviewed the appeal and issued a letter dated July 31, 2017, advising that it had overturned the 50% penalty.  An additional payment for the balance of the penalty was issued on August 24, 2017.  In the interim, on August 15, 2017, Claimant filed a Demand for Arbitration seeking the balance of the bill.  Mr. Lagana successfully convinced the Dispute Resolution Professional that, pursuant to the Decision Point Review Plan Allstate had 45 days from the post-service appeal to correct the payment dispute before Claimant was able to initiate dispute resolution.  Therefore, because the Demand for Arbitration was filed before this timeframe expired, Allstate had been wrongly prohibited from completing its review and correcting the erroneous penalty.  As a result, Claimant’s Assignment of Benefits was voided and the Demand for Arbitration was denied in its entirety.