A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL

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1 CASE NO. 18 Z A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z v. INS. CO. CLAIMS NO.: Allstate Insurance Company DRP NAME: James H. Garrabrandt (Respondent) NATURE OF DISPUTE: Independent Consultative Opinion AWARD OF DISPUTE RESOLUTION PROFESSIONAL I, THE UNDERSIGNED DISPUTE RESOLUTION PROFESSIONAL (DRP), designated by the American Arbitration Association under the Rules for the Arbitration of No-Fault Disputes in the State of New Jersey, adopted pursuant to the 1998 New Jersey Automobile Insurance Cost Reduction Act as governed by N.J.S.A. 39:6A-5, et. seq., and, I have been duly sworn and have considered such proofs and allegations as were submitted by the Parties. The Award is DETERMINED as follows: Injured Person(s) hereinafter referred to as: AT. 1. ORAL HEARING held on December 16, ALL PARTIES APPEARED at the oral hearing(s). NO ONE appeared telephonically. 3. Claims in the Demand for Arbitration were NOT AMENDED at the oral hearing (Amendments, if any, set forth below). STIPULATIONS were not made by the parties regarding the issues to be determined (Stipulations, if any, set forth below). 4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW: This matter arose out of a motor vehicle accident that occurred on September 27, 2002 and is, therefore, subject to AICRA. Claimant seeks additional reimbursement in the amount of $39.69 for an office visit conducted on February 6, 2003 and billed under CPT and payment of $ for a narrative report generated on February 6, 2003 and billed under CPT

2 CASE NO. 18 Z The treating chiropractor, Dr. Burrini, referred AT to Claimant for a medical consultation. An independent consultative opinion is expressly permitted under the New Jersey Care Paths. An independent consultative opinion is defined in N.J.A.C. 11: as a Physical examination by a physician of similar specialty to the injured person's treating practitioner to provide a second medical opinion. The independent physician may support, refute, or provide alternatives to the current diagnosis and treatment plans. Claimant conducted, billed under CPT and was only paid $ for the independent consultation. Respondent unilaterally downcoded CPT to CPT Nowhere of record, though, does Respondent reveal the identity, or credentials of the person(s) who made the determination regarding the downcoding, or the statutory, administrative code or other authoritative basis upon which it was done. The downcoding was improper and, therefore, Claimant is entitled to further reimbursement in the amount of $39.69 for the office visit. It should also be noted that the payment of $ was made on October 24, Inasmuch as the payment was made after the filing of the Demand for Arbitration (August 11, 2003), it will be taken into consideration in determining an appropriate and reasonable attorney's fee for Claimant's counsel in this case. Respondent did not reimburse Claimant for the report billed under CPT The independent consultation was conducted on February 6, Following the consultation, Claimant issued, and provided the treating chiropractor, Dr. Burrini, with a written report containing history and consultation, past history, physical examination, range of motion study, diagnosis and recommendations. Claimant billed its usual and customary fee of $ under CPT for the report. Under the 2003 AMA/CPT Manual, CPT is described as Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form. In the 2003 AMA/CPT Manual, a consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source... The consultant's opinion and any services that

3 CASE NO. 18 Z were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source. Consultation encompasses CPT codes through A written report is contemplated as part of the office consultation. It is, in fact, a required component of the office visit. There is no evidence of record to establish, or even suggest that the report generated by Claimant was anything other than the type of report used to document an independent consultation, support billing under CPT for it and communicate a consultative opinion to the treating physician. There is nothing "special" about the report generated by Claimant following the independent consultation conducted on February 6, It contains nothing more than information conveyed in the usual medical communications or standard reporting form. The office consultation, with accompanying report, then, should be billed as one procedure under CPT To do otherwise would constitute "unbundling;" which is prohibited under N.J.A.C. 11:3-29.4(g). The claim for reimbursement in the amount of $ for a report billed under CPT is denied. Medical expense benefits are awarded as outlined hereinabove and set forth in Paragraph 5, below. Claimant's counsel seeks attorney's fees in this matter. N.J.A.C. 11:3-5.6(d)3 provides that the decision of the dispute resolution professional "may include attorney's fees for a successful claimant in an amount consonant with the award and with Rule 1.5 of the Supreme Court's Rules of Professional Conduct." The request for attorney's fees, as well as Respondent's argument that the attorney's fees being sought by Claimant's counsel are excessive have been taken into consideration. As set forth in RPC 1.5, consideration has also been given, but not limited to, the novelty and difficulty of the questions involved, the skill requisite to perform the legal services properly, the fees customarily charged in the locality for similar legal services, the amount involved and the results obtained, as well as the experience, reputation and ability of the lawyer performing the service.

4 CASE NO. 18 Z An award of attorney's fees of $ is consonant with the amount of the Award, together with the amount paid by Respondent after the filing of the Demand for Arbitration and in keeping with the guidelines of RPC 1.5. Claimant seeks costs in the amount of $ (AAA filing fee - $285.00). N.J.A.C. 11:3-5.6(d)2 provides that the award "shall apportion the costs of the proceedings, regardless of who initiated the proceedings, in a reasonable and equitable manner consistent with the resolution of the issues in dispute." Consistent with the provisions of N.J.A.C. 11:3-5.6(d)2, costs are awarded in the amount of $ MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to Advanced Rehabilitation Institute $ $39.69* Advanced Rehabilitation Institute Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. *Net Award 6. INCOME CONTINUATION BENEFITS: Not In Issue 7. ESSENTIAL SERVICES BENEFITS: Not In Issue 8. DEATH BENEFITS: Not In Issue 9. FUNERAL EXPENSE BENEFITS: Not In Issue 10. I find that the CLAIMANT did prevail, and I award the following COSTS/ATTORNEYS FEES under N.J.S.A. 39:6A-5.2 and INTEREST under N.J.S.A. 39:6A-5h.

5 CASE NO. 18 Z (A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $ (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $ (C) INTEREST is as follows: waived per the Claimant.. This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. January 16, 2004 Date James H. Garrabrandt, Esq.

A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL

CASE NO. 18 Z 600 17264 02 2 A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z 600 17264 02 v.