Tuesday, November 24, 2020

$481.30 Awarded on a $62,830.97 No-Fault Claim -- Coronary Bypass Surgery and Related Hospital Services Found Unrelated to the MVA


Matter of United Health Services Hospital  aao JK and Preferred Mutual Ins. Co.
(AAA Case No. 17-18-1089-4199, issued 11/23/2020)

78-year old man passes out driving and crashes.  At the hospital, he is found to have suffered a myocardial infarction and severe coronary artery disease.  Eight days, one coronary bypass surgery and $62,830.97 later, he goes home.  A few weeks later, the hospital bills the man's no-fault insurer, Preferred Mutual, for the cost of the heart surgery and related services.  Preferred Mutual obtains a cardiologist's peer review opinion and denies payment.  Approximately four years and 100% in interest later, the hospital demands AAA arbitration of the denial. 

After a hearing, AAA Arbitrator Fred Lutzen concluded:
After reviewing the entire peer review and the submitted records, I find the peer provides a satisfactory medical rationale and relies on the facts present, so that Respondent has met its burden and proven, prima facie, that the hospital services and surgery related to his heart condition were unrelated to the motor vehicle accident. 
The arbitrator did award the hospital a total of $481.30 for the ER charge and a CT scan.  

Ryan Mura of this office ably defended Preferred Mutual's denial position in this arbitration.  Nice job, Ryan.   

1 comment:

Ryan Mura said...

In the award, Arbitrator Lutzen characterized the peer review report as being "well-reasoned and persuasive", which highlights the importance of having a medical opinion to support a defense based on lack of causation. While it might seem obvious to some that medical treatment for a heart attack is not related to injuries sustained in a motor vehicle incident, a medical opinion to support that conclusion is still necessary to make the defense viable.

The arbitrator also took note of the fee schedule calculations prepared by our certified professional coder, Melissa Kurgan. The practice point here is that arbitrators routinely require carriers to prove a fee schedule defense with evidence of the proper calculation.

Please feel free to reach out to me directly by email (ryan.mura@muralaw.com) if you have any questions about the award or its findings.