The New Jersey Department of Banking and Insurance adopted new PIP regulations on Nov. 15, 2012, the main parts of which and the fee schedule will go into effect 60 days hence.
The regulations are located here. First introduced in 2011, they have prompted a firestorm of criticism from the healthcare community, says Jeff Shanton, administrator of Journal Square Surgical Center. "The Department has seen fit to adopt in its entirety (rules and fee schedule 2011 CMS, which we feel is dead wrong," he says. "Use of the Medicare fee schedule as methodology is incorrect, as the statute (NJSA 39:6) clearly states: shall incorporate reasonable and prevailing fees of 75 percent of practitioners within the region."
The use of CMS procedures that can be performed in an ASC is also inappropriate, Mr. Shanton says. "Up until the last minute, we were engaged with the Department on this issue," he says. "Inclusion of procedures on the CMS-approved list is oft times more political than medical, with CMS not always keeping abreast of the latest technological innovations and breakthroughs."
At the heart of the issue, he says, is the fact that while the procedures in question are not performed on Medicare-aged patients, they are performed on PIP patients. This patient group is a different and more robust demographic, Mr. Shanton says.
There is no venue for payment or arbitration of procedures not listed on the fee schedule, according to current regulations. A HOSF fee schedule has also been added.
"Procedures that have been routinely and safely performed and paid for in an ASC setting will now be forced to either HOSF, which is paid 43 percent more for the same procedure, or in-patient hospital, with no fee schedule at all, with increased cost for the patient and the MVA carrier," Mr. Shanton says. "Quite honestly, the Department has no regulatory or statutory authority to determine what procedures can and cannot be performed in a particular setting."
The NJAASC on Nov. 5 sent an appeal for a stay of the regulations to the Department, and filed notice of this appeal with the Superior Court of New Jersey, Appellate Division.
"We expect the Department to reject our appeal, thus the decision will
be left up to the Court," Mr. Shanton says. "We trust the Court will agree with our arguments and issue a stay on implementation, as they did in 2007."
The regulations are located here. First introduced in 2011, they have prompted a firestorm of criticism from the healthcare community, says Jeff Shanton, administrator of Journal Square Surgical Center. "The Department has seen fit to adopt in its entirety (rules and fee schedule 2011 CMS, which we feel is dead wrong," he says. "Use of the Medicare fee schedule as methodology is incorrect, as the statute (NJSA 39:6) clearly states: shall incorporate reasonable and prevailing fees of 75 percent of practitioners within the region."
The use of CMS procedures that can be performed in an ASC is also inappropriate, Mr. Shanton says. "Up until the last minute, we were engaged with the Department on this issue," he says. "Inclusion of procedures on the CMS-approved list is oft times more political than medical, with CMS not always keeping abreast of the latest technological innovations and breakthroughs."
At the heart of the issue, he says, is the fact that while the procedures in question are not performed on Medicare-aged patients, they are performed on PIP patients. This patient group is a different and more robust demographic, Mr. Shanton says.
There is no venue for payment or arbitration of procedures not listed on the fee schedule, according to current regulations. A HOSF fee schedule has also been added.
"Procedures that have been routinely and safely performed and paid for in an ASC setting will now be forced to either HOSF, which is paid 43 percent more for the same procedure, or in-patient hospital, with no fee schedule at all, with increased cost for the patient and the MVA carrier," Mr. Shanton says. "Quite honestly, the Department has no regulatory or statutory authority to determine what procedures can and cannot be performed in a particular setting."
The NJAASC on Nov. 5 sent an appeal for a stay of the regulations to the Department, and filed notice of this appeal with the Superior Court of New Jersey, Appellate Division.
"We expect the Department to reject our appeal, thus the decision will
be left up to the Court," Mr. Shanton says. "We trust the Court will agree with our arguments and issue a stay on implementation, as they did in 2007."