Publication Details

CLMC PIP Department Successfully Defends Clients on ASC Reimbursement Issue

CLMC PIP Department Successfully Defends Clients on ASC Reimbursement Issue

The issue of whether or not a PIP carrier can be compelled to reimburse an Ambulatory Surgery Center (“ASC”) for surgical procedures that are not listed on the ASC Fee Schedule continues to be decided inconsistently by Forthright arbitrators.  However, over the past several months, CLMC’s PIP Department has successfully overturned several unfavorable awards on this issue by utilizing Forthright’s appellate process, as well as Orders to Show Cause filed in Superior Court.

In the matters of Allstate v. Pleasantdale Ambulatory Care a/s/o T.N. v. Allstate, (BER-L-5311-18, 9/17/18) and Allstate v. Palisade Surgery Center a/s/o A.J. v. Allstate, (BER-L-4163-18, 10/3/18), Richard W. Fogarty succeeded in overturning Forthright arbitration awards in favor of ASCs for surgical procedures represented by CPT codes 63020 and 22554, respectively.  Mr. Fogarty obtained review of the underlying arbitration awards under N.J.S.A. 2A:23A-13.  The Trial Court Judge agreed with Mr. Fogarty in both matters, ruling that the language of New Jersey Administrative Code sections N.J.A.C. 11:3-29.4(e)(3) and N.J.A.C. 11:3-29.5(a) was clear and provided that codes not listed on the ASC Fee Schedule were not reimbursable to an ASC.  More recently, Mr. Fogarty successfully convinced two Forthright appellate panels to overturn awards of surgical codes 63030 and 63056 to ASCs in the matters of Essex Surgical Center a/s/o I.G. v. Allstate, (Forthright File #1768664, 12/5/18) and Manalapan Surgery Center a/s/o A.C. v. MetLife, (Forthright #1769136, 12/12/18) through a similar analysis.