$6,000,000 RECOVERY - PLAINTIFF CROSSWALK PEDESTRIAN STRUCK BY SCHOOL BUS TURNING LEFT FROM BEHIND HER AFTER PLAINTIFF REACHES MIDDLE AREA OF ROADWAY - PLAINTIFF DRAGGED APPROXIMATELY 20 FEET BEFORE BUS STOPS WITH WHEEL ON TOP OF PLAINTIFF - PLAINTIFF IS CONSCIOUS AND IN GREAT PAIN FOR APPROXIMATELY ONE HOUR BEFORE EXTRICATED - BURST THORACIC FRACTURE - LUMBAR AND THORACIC COMPRESSION FRACTURES - FUSION IN THORACIC AREA - SEVERE DEGLOVING INJURY TO LOWER LEG - CONTINUING RISK OF INFECTION IN LEG BECAUSE OF FLUID BUILDUP - TEMPORARY INCONTINENCE - PTSD.

Bergen County, NJ

In this action, the plaintiff in her mid 20s contended that after she had crossed more than half of the roadway containing one travel lane in each direction, she was struck by the left side view mirror of the bus and pulled under the left front wheel of the bus. The plaintiff contended that as a result, she suffered a burst fracture in the thoracic spine, thoracic and lumbar compression fractures, a severe degloving injury to the lower left leg, bowel and bladder incontinence that resolved after some months, and PTSD. The plaintiff has already undergone some eight major surgeries, including a fusion in the thoracic area, and the insertion of a V.A.C. therapy unit to the lower leg, and contended that she may well require additional surgery in the future.
The bus driver had given the police a videotaped, sworn statement that the plaintiff ran in front of the bus. The plaintiff contended that this statement was inconsistent with the physical evidence that the plaintiff was initially struck by the driver's side view mirror of the bus and the defendant driver indicated during her deposition, that her earlier statement was inaccurate.
The plaintiff maintained that it took almost an hour to extricate her from under the bus. The plaintiff would have stressed that during this period, she was conscious and in great pain, and that one of the first responders continued to hold her hand, attempting to reassure her.
The plaintiff was unable to walk after the collision. She underwent extensive physical and occupational therapy and ultimately regained such ability, albeit with a moderate limp. The plaintiff required a total of some eight major operative procedures, including a fusion in the thoracic area and the installation of a VAC therapy device to help treat the degloving injury in the lower leg. The plaintiff contended that she will permanently suffer fluid build-up, be at increased risk of infection, and may well need surgery in the future.
The plaintiff further maintained that she suffered a severe post traumatic stress disorder that has caused symptoms that include anxiety, depression and flashbacks of the event. The plaintiff would have contended that she will permanently suffer symptoms despite psychotherapy.
The plaintiff also maintained that she will incur extensive future costs, including costs for medical care and alterations to her home. The plaintiff would have introduced evidence of an approximate $5,000,000 life care plan.
The plaintiff was attending college part time and working part time when the incident occurred. The plaintiff contended that because of the injuries, it is doubtful that she will be able to work in the future.

The case settled prior to trial for $6,000,000.

On November 3, 2010, Eric Katz, New Jersey health care trial and class action attorney, made a presentation to the New Jersey Hospital Association in Princeton.  Mr. Katz discussed his land mark physician class action settlement against Horizon Blue Cross and how certain aspects of that settlement would be highly beneficial to New Jersey's hospitals.  The presentation was attended by over 50 hospital executives.

Sutter-Settlement-Powerpoint.pdf (867.04 kb)

I am pleased to announce that the 2011 edition of my treatise on products liability and toxic torts is now on sale.  This book, widely-recognized as the leading products liability treatise in New Jersey is used by thousands of lawyers and judges and is often cited by the Appellate Division and the Supreme Court of New Jersey.  It is published by Gann Publishing in Newark New Jersey and contains almost 1200 pages of analysis of the law and cases in these two ever changing and important areas of the law.

Product Liability Book Cover.pdf (123.18 kb)

On June 8, 2010, I presented a detailed seminar, including questions and answers, to professional coders in Newton, NJ.  The issues, all relevant to managed care and related billing, included prompt payment, bundling, downcoding, no-fault, workers' compensation and so forth.  The powerpoint presentation used is attached.

Promp-Pay-Powerpoint.pdf (1.17 mb)

A class action settlement, valued as much as $50 million, between New Jersey physicians and Horizon Blue Cross Blue Shield of New Jersey was approved by the Superior Court of New Jersey on June 16th.  The settlement removes the "black box" in which Horizon has been processing claims submitted by physicians.  Under the settlement terms, among several other benefits, Horizon must dislcose to physicians all fee schedule information and provide an interactive web tool that allows physicians to input procedure codes before services are rendered in order to learn how Horizon will process and pay those codes.  In addition, a dedicated liaision was established to assist capitated physicians to enable them to be paid properly and quickly for the services they render.  Our law firm represented the Class in this action.  The Court's complete opinion is attached to this post.

Sutter Opinion.doc (77.50 kb)

United States Senator Frank Lautenberg has asked the IRS to examine the compensation package for Horizon Blue Cross Blue Shield's CEO William Marino.  Incredibly, while physicians are repeatedly pinched for every penny they earn from treating Horizon members, Marino recently walked off with salary and bonuses totaling $8.7 million last year -- from a company that is not-for-profit.  Senator Lautenberg said he is contemplating legislation to rein in the pay of Blue Cross executives.  We laud Senator Lautenberg's actions. 

Just what is the United States Supreme Court doing?  It is clear that this conservative Court is attempting to do away with all legal devices available to consumers of this country seeking to vindicate their rights against corporate America. 

So what does Stolt-Nielsen (U.S Supreme Court decision from April 27th) actually hold?  The majority opinion requires that there be a contractual basis -- in other words an "agreement" -- between the parties to engage in class arbitration of the claims and that the parties cannot be compelled to arbitrate on a class-wide basis based simply based on legitimate "public policy" to do so. 

Significantly, Justice Ginsburg, in a well written dissent, correctly observed that the majority left open the issue of what would constitute an "agreement" to arbitrate a class action.  She further pointed out that the parties in Stolt-Nielsen were "sophisticated" business entities that knew what they were doing when they negotiated their agreement.  Of course, virtually 99% of the time that is not the case and certainly never the case with the average consumer that is compelled to take a contract as presented with no opportunity whatsoever to negotiate terms.  

So the bottom line is that the Stolt-Nielsen majority decision, which is sure to sporn all sorts of new litigation as to what constitutes an "agreement" to class arbitration, may not really impact the average consumer seeking to enforce his/her rights afterall.  Only a class action lawyer can tell you that for sure and I urge you to consult one if you have any thoughts of pursuing legal remedies on behalf of yourself and a class of other similarly affected individuals.  

Slow claim payment is a major concern for physicians and other providers and results in a very damaging impact on practices. Under the New Jersey prompt payment laws, managed care organizations are required to reimburse physicians and dentists within set time frames. For noncapitated, fee for service fully insured claims, they must pay within 30 days after receiving an electronic claim and 40 days of one sent by regular mail. For capitated claims, the insurer must pay no later than 5 days of the due date set forth in the provider agreement. In addition, the insurer must contact a provider within those same time frames to request missing or incomplete claim information in order to process the claim. As of July 2006, the carrier must now request such information within 7 days when the claim is submitted electronically.

There are significant consequences to the carrier for non-compliance. If the insurer fails to pay or deny the claim or fails to request missing or incomplete information timely and by expeditious means, it waives the right to contest payment of that claim unless the claim was submitted fraudulently. In other words, if it turns out that the claim could have been properly denied because there was no coverage on the date of service, but the carrier did not tell the doctor that until after the statutory deadline, the claim must now be paid. Moreover, under the law, physicians are entitled to interest on all late paid claims. Prior to July 2006, companies were charged 10% annual interest. The rate is now 12%.

There are simple steps that you can take to help ensure the fastest possible turnaround on claims payment:

• Submit Electronically: The benefits include faster processing times, fewer errors and less missing information.
• Send “Clean Claims”: A “clean claim” is a complete claim containing all information requested on the claim form. Take the time to ensure that your HCFA-1500 forms or equivalent forms are filled out fully and accurately.
• Don’t Resubmit: Submit a claim only once. Duplicate submissions can backfire because HMOs often recognize them as the “only” claim and ignore the original- which delays payment to the doctor.
• Establish Policies: Set and follow internal procedures. Submit claims the same or next day after the service is provided. Use a practice management software package to build monthly reports to track and document all transactions, including all communications and telephone calls to the carrier to follow-up on outstanding claims.
• Involve Patients: Communicate with patients from the start. Inform them that their participation in the claim process might be necessary to provide the insurer with additional information. Prepare a written cooperation agreement with the patient.

Maximizing Usual, Customary and Reasonable Reimbursement

The “Usual, Customary and Reasonable" (UCR) for a procedure is an ongoing debate between non-participating physicians and insurance companies. When carrier fee schedules and reimbursement policies do not coincide with the realities of a practice’s UCR, physicians get short-changed.

You can maximize your reimbursement by implementing the following practical tips.

• Enlist a Service: Leverage available software and services. Companies like
Ingenix, among other useful offerings, provide solutions to help calculate UCRs. Remember that a true UCR is based on what providers with the same background and experience charge for the same service in your geographic region. Thus, the UCR for a particular procedure rendered by a spine surgeon in Bergen County may be different than in Gloucester County.

• Establish “Comparable” Reimbursements: Save your explanations of benefits
with highest reimbursement rates for particular CPT codes. Then use these
“comparables” as proof of your UCRs when an insurer disputes the level of
payment.

• Document Emergencies: Carefully track your emergency services. They are
typically reimbursed at 100% of the UCR.

• Obtain Pre-certification: For non-emergency services, obtain pre-certification
and verify payment terms with the carrier - by calling the phone number on the
back of the patient’s insurance card - before rendering services. Confirm that
you will get paid at the doctor’s UCR. Then document the approval in the
patient’s chart or your practice management software, including who you spoke to, when and the terms that were verified.

• Get Upfront Payment: Obtain pre-payment from patients whenever possible
and particularly when you have doubts about the availability of insurance or the patient’s ability to pay at a later date. A credit card is preferable for full recourse if there is a dispute.

About Class Actions

Eric Katz and the attorneys in his New Jersey law firm have extensive experience in handling class actions against major managed care organizations.  Mr. Katz is lead class counsel in several class actions filed against the managed care industry on behalf of physicians and dentists seeking prompt and appropriate payment of claims. In one case, Mr. Katz settled a landmark $39 million class action on behalf of tens of thousands of New Jersey physicians against Horizon Blue Cross Blue Shield of New Jersey.

In another physician class action filed by Mr. Katz on behalf of approximately 20,000 New Jersey physicians against Oxford Health Plans, the United States Court of Appeals for the Third Circuit recently upheld the arbitrator’s certification of that action as a class action.This physician class action is one of the first in the country to be certified as a class action in arbitration. Mr. Katz and the attorneys in his New Jersey law firm also represent the interests of patients against managed care organizations for their wrongful denial of coverage and benefits and, for example, filed a class action against Horizon Blue Cross Blue Shield of New Jersey for its improper denial of coverage to victims of eating disorders. The case later settled with another similar class action.  As part of the settlement, Horizon agreed to cover eating disorder treatment claims in "parity with," in other words the same as other claims.

Mr. Katz and the class action attorneys in his New Jersey law firm also represent plaintiffs in a variety of consumer class actions, including nationwide litigation against automobile manufacturers regarding product defects, litigation against automobile insurers for their failure to properly cover various kinds of claims, and so on.

In our prosecution of class actions, we commit every possible resource into developing and litigating the claims so as to ensure the maximum possible recovery to the class.  If you believe that you have a claim that is appropriate for class action representation, please contact Mr. Katz and he will contact you within twenty-four (24) hours to discuss your case.