Negative Peer Reviews and the PA Act 6 Law

Healthcare providers who provide services and treatment to individuals who are injured in an automobile accident rely on first party medical benefits for reimbursement from the insurance policy covering the individual. Under Pennsylvania’s Motor Vehicle Financial Responsibility Law (MVFRL), automobile liability policies are required to provide a medical benefit in the amount of $5,000.00 or more. When the patient seeks medical treatment, the healthcare provider treats the patient and then the provider submits the claims for payment to the insurance. The insurance payer will then reimburse the provider for the services, but the amount cannot exceed the total benefit available. If the benefit has reached its maximum, then the provider must either seek payment from the patient’s health insurance or directly from the patient. Under the MVFRL, the automobile insurance carrier can challenge whether the services provided are reasonable and necessary. If the insurer is successful in its challenge, then the healthcare provider cannot collect payment for the medically unnecessary services or treatment.

PA Act 6 and the Peer Review

The PA MVFRL requires insurers to contract with a peer review organization (PRO). When the insurer receives a bill from the provider, the insurer has ninety (90) days to submit a challenge to the PRO. The PRO will assign a reviewer to review the medical record documentation to determine whether the services are reasonable and necessary. The PRO shall also afford an opportunity for the provider to discuss the case with the reviewer. A report will then be issued by the PRO within thirty (30) days after its receipt of the medical record documentation. If the PRO determines that the services are not reasonable and necessary, then the insurer has a legal basis to not pay for those services.

PA Act 6 appeals and reconsideration

Following a negative peer review, the provider may appeal the decision to court or request a reconsideration. Usually, the appeal has more favorable outcomes for the provider in comparison to the reconsideration. If the provider is successful following the appeal, which means that the court determines that the services were medically necessary, then the insurer must pay to the provider the outstanding amount plus interest at the rate of 12%, as well as the costs of the challenge and all attorney fees.

PA Act 6 Attorney

Providers should hire an attorney during the appeal process. Healthcare attorneys who have experience with Act 6 cases will be able to focus in on the statutory and procedural requirements of the Peer Review in order to overturn the PRO determination.

PA Act 6 Peer Review Rules

Insurers must comply with all statutory and procedural rules for submitting challenges to the PRO. If the Insurer or the PRO does not conduct themselves properly, the failure to comply with the MVFRL can result in a successful appeal for the provider. These are some examples:

A provider’s bill shall be referred to a PRO only when sufficient reasons exist to believe that a PRO is necessary.

  • The insurer must notify the provider in writing when referring bills for PRO review.
  • The insurer must make the referral to the PRO within 90 days of receipt of sufficient documentation supporting the bill.
  • The PRO must afford the provider an opportunity to discuss the case with the reviewer;
  • The PRO must afford the provider an opportunity to submit information.
  • The PRO determination must be made within 30 days after receipt of the requested information.
  • The PRO must provide a written analysis with specific reasons for its decision.
  • The review must be performed by a licensed practitioner of like specialty or a licenses practitioner with experience providing and prescribing the care subject to the review.

In addition to these statutory and procedural requirements, the report itself must be reviewed and analyzed. The PRO should apply national and regional norms when conducting determinations. If these norms do not exist then the PRO must establish written criteria to be used in conducting the reviews based upon standards of practice in the PRO’s region.

Providers should always consider appealing the PRO determinations. Healthcare attorneys who focus on Act 6 cases often handle appeals on a contingency basis. If successful on appeal, the MVFRL requires the insurers to cover the provider’s costs and attorneys’ fees.

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