Q/A: What do I do When my State Doesn't Require Pre-certifications for PI, but the Payer in Another State Does?

by  Wyn Staheli, Director of Content - innoviHealth
Nov 7th, 2018

Question: 

In Pennsylvania for Personal Injury cases we do not need to go through specific care paths or get precertification in order to treat patients, however, in New Jersey (NJ), doctors that practice there are required to get that precertification. Our question is that when we bill a New Jersey auto insurance company they are stating that we need to get precertification when we do not because we are based in Pennsylvania. What would be the best way to get the insurance companies to understand and not argue with us about the fact that we do not have to get precertification? Is there a specific way to communicate that to an insurance company from a different state?

Answer: 

This sounds like you are dealing with a situation called diversity jurisdiction. The prevailing law is based on where the accident occurred as well as the physical location of the insured that was at fault. The insurance company must abide by the prevailing law. Therefore, if either the accident or the insured is located in the state of NJ, then you must also follow NJ law and obtain precertification.

Even if you are required to follow their precertification requirements, you are not necessarily required to accept that payers fee schedule and could potentially balance bill the remainder of the bill to supplemental insurance or the client.

In situations like this, a good attorney can help you to navigate these muddy waters. Also, according to one consultant, if the injured person has a valid Pennsylvania policy with PIP, that policy can cover the initial medical costs while this gets addressed by an attorney.