Award of Dispute Resolution Professional

Transcription

1 In the Matter of the Arbitration between Bergen Ambulatory Surgery Center A/S/O R.Q. CLAIMANT(s), Forthright File No: NJ Insurance Claim File No: Claimant Counsel: Law Offices of Fano & Krug, P.C. v. Claimant Attorney File No: Respondent Counsel: Pomeroy, Heller & Ley, LLC Respondent Attorney File No: Accident Date: 08/25/2009 New Jersey Manufacturers Ins Group RESPONDENT(s). Award of Dispute Resolution Professional Dispute Resolution Professional: Joseph J. Riva, Esq. I, The Dispute Resolution Professional assigned to the above matter, pursuant to the authority granted under the Automobile Insurance Cost Reduction Act, N.J.S.A. 39:6A-5, et seq., the Administrative Code regulations, N.J.A.C. 11:3-5 et seq., and the Rules for the Arbitration of No-Fault Disputes in the State of New Jersey of Forthright, having considered the evidence submitted by the parties, hereby render the following Award: Hereinafter, the injured person(s) shall be referred to as: Patient An oral hearing was waived by the parties. An oral hearing was conducted on: 05/02/12 Hearing Information Claimant or claimant s counsel appeared in person. Respondent or respondent s counsel appeared in person. The following amendments and/or stipulations were made by the parties at the hearing: The amount in dispute is $29, NJ Page 1 of 12

2 Findings of Fact and Conclusions of Law This arbitration arises out of an automobile accident that occurred on 08/25/09. On that date, R.Q.s (patient) was an insured of New Jersey Manufacturers Ins Group (respondent) and eligible to receive personal injury protection (PIP) benefits when he suffered injuries because of the accident. Patient received medical care at Bergen Ambulatory Surgery Center (claimant). Claimant took an assignment of patient s claim for PIP benefits. After a dispute arose regarding those benefits, claimant commenced this proceeding, seeking reimbursement from respondent of $29, with interest for unpaid medical bills together with counsel fees and costs. The reimbursement claim is laid out in claimant s Arbitration Summary. The issues identified by the parties, confirmed by counsel at the arbitration hearing held on 05/02/12, and presented for my consideration are: (1) whether claimant unbundled CPT code from CPT code for the 01/25/10 and 02/15/10 dates of service; (2) whether claimant unbundled CPT code from CPT code for the 04/09/10 date of service; (3) whether the Multiple Procedure Reduction (MPR) formula applies to CPT codes and 22899; (4) whether the award of Dispute Resolution Professional Sergio G. Carro, Esq. in Northern NJ Ortho Specialists a/s/o R.Q. v. New Jersey Manufacturers Ins Group, NJ precludes the re-litigation of certain issues; (5) whether claimant lacks standing by failing to appeal the 04/09/10 date of service; and (6) counsel fees and costs. The parties did not present any other issues. They agreed that only the issues presented would be decided. Accordingly, I have not considered nor decided any other issues. The parties submitted a number of documents in support of their respective positions for my review, including: Claimant s Demand for Arbitration with attached Exhibits A and B, Claimant s 02/07/12 submission with attached Exhibits A through N, Claimant s 04/25/12 submission with attached Exhibits A through C, Claimant s 05/02/12 post-hearing submission with attached Exhibits I through VI, Claimant s 05/08/12 post-hearing submission with attached Exhibits A and B, Claimant s post-hearing PIP Arbitration Attorney Fee Certification, Respondent s 04/03/12 submission with attached Exhibits A through U, Respondent s 04/03/12 submission with attachment, and Respondent s 05/04/12 post-hearing submission with attachments. I have carefully reviewed all of the parties submissions and considered the arguments of counsel advanced at the hearing. Epidurography and Fluoroscopy Respondent appropriately reimbursed claimant $1, for the epidural injection on 01/25/10 and $1, for the epidural injection on 02/15/10. As to each of these dates of service, claimant is seeking reimbursement of $ for epidurography billed under CPT code TC. Claimant is NJ Page 2 of 12

3 also seeking reimbursement of $ for fluoroscopic guidance under CPT code TC as to the 04/19/10 date of service. It is respondent s position that pursuant to N.J.A.C. 11:3-29.4(o)4, these procedures are diagnostic services, which are included as part of the underlying facility fee for an ambulatory surgical center (ASC) and, therefore, not subject to separate reimbursement. I agree. The Department of Banking and Insurance (DOBI) has addressed this specific issue on its website as follows: Q. The Fee Schedule rule at N.J.A.C. 11:3-29.4(o)4 states that diagnostic and therapeutic items are included in the ASC facility fee. Does this mean that all diagnostic tests (CPT codes through 89999) are included in the facility fee? In particular, is CPT 77003, Flouroscopic guidance, included in the facility fee? A. The Department follows relevant provisions of the Medicare payment system. Since the adoption of the amendments to the Fee Schedule, Medicare has updated its ASC payment system. It publishes a list of ASC Covered Ancillary Services Integral to Covered Surgical Procedures. The entire list, which can be downloaded from CMS, includes 15 CPT codes that are on the Department s Physicians Fee Schedule. These codes (listed below) from Addendum BB have the indicator N1 Packaged service/item; no separate payment made Contrast x-ray, thorax spine Contrast x-ray, lower spine Epidurography X-ray c/t spine disk X-ray of lower spine disk Contrast x-ray of shoulder Contrast x-ray of hip X-ray exam, sacroiliac joint Contrast x-ray of ankle Fluoroscope examination d render w/o postprocess d rendering w/postprocess Echo guide for biopsy Needle localization by x-ray Fluoroguide for spine inject [See Auto Medical Fee Schedule Frequently Asked Questions.] Because CPT codes and are included on the list of ASC Covered Ancillary Services Integral to Covered Surgical Procedures, I deny reimbursement for these codes. NJ Page 3 of 12

4 MPR Formula CPT code The procedure performed at claimant s facility on 04/09/10 was billed by claimant as CPT code 62290, which the American Medical Association CPT Manual (the Manual) defines as an [i]njection procedure for discography, each level; lumbar. Simply put, this code refers to the injection procedure involved in the process of making a discogram, which is a radiograph of an intervertebral disc made after injection of a radiopaque injection. Regarding the injections patient received at L3-L4, L4-L5 and L5-S1 on 04/09/10, claimant argues that the MPR formula does not apply. In support of this argument, claimant relies on N.J.A.C. 11:3-29.4(f)(2), which provides: There are two types of procedures that are exempt from the multiple procedure reduction. Codes in CPT that have the note, Modifier -51 exempt shall be reimbursed at 100 percent of the eligible charge. In addition, some related procedures are commonly carried out in addition to the primary procedure. These procedure codes contain a specific descriptor that includes the words, each additional or list separately in addition to the primary procedure. These add-on codes cannot be reported as stand-alone codes but when reported with the primary procedure are not subject to the 50 percent multiple procedure reduction. By contrast, it is respondent s position that even though the MPR formula exempts procedures with the words each additional as to physicians, there is no such exemption for ASCs. In support of this argument, respondent relies on N.J.A.C. 11:3-29.4(q), which provides: When multiple procedures are performed in an ASC in the same operative session, the ASC facility fee for the procedure with the highest payment group number is reimbursed at 100 percent and reimbursement of any additional procedures furnished in the same session is 50 percent of the applicable facility fee. For example, if two Group 2 procedures and a Group 1 procedure are all performed in the same operative session, reimbursement of the ASC facility fee is 100 percent of the first Group 2 fee plus 50 percent of the second Group 2 fee, plus 50 percent of the Group 1 fee. Undoubtedly, N.J.A.C. 11:3-29.4(f)(2) applies to the physicians performing procedures while N.J.A.C. 11:3-29.4(q) refers to an ASC. Moreover, it bears particular note that DOBI chose not to repeat the exclusionary language of N.J.A.C. 11:3-29.4(f)(2) in the regulatory provision pertaining to ASCs. There are 2 questions and answers on DOBI s website that illuminate the issue: Q. Does the provision in N.J.A.C. 11:3-29.4(f) apply to facility fees billed by ASC s pursuant to N. J.A.C. 11:3-29.4(q)? A. The procedures concerning billing for bilateral and co-surgeries and exemptions from the multiple procedure reduction formula listed in N.J.A.C. 11:3-29.4(f) are intended to apply only to the physicians fee schedule. However, the Department has followed relevant provisions of the Medicare Claims Processing Manual in the Fee Schedule Rule. The Medicare Claims Processing Manual for ASC s states that, A procedure performed NJ Page 4 of 12

5 bilaterally in one operative session is reported as two procedures. Treat payment for a procedure performed bilaterally the same as payment for multiple procedures. Therefore, the Department believes that it is appropriate to apply this provision to bilateral surgeries performed in ASC s. Q. Does the fact that Medicare includes ASC s in the definition of physician in its rules for interpretation of the National Correct Coding Initiative (NCCI) mean that add-on codes as defined in N.J.A.C. 11:3-29.4(f) are not subject to the multiple procedure reduction formula in an ASC? A. No. As noted above in response to the previous question, the provisions of N.J.A.C. 11:3-29.4(f) only apply to billing by physicians. The rule for application of the multiple procedure reduction (MPR) formula to ASC facility fees is found in N.J.A.C. 11:3-29.4(q). There is absolutely no relation between the NCCI edits and the MPR formula. The NCCI edits prevent unbundling separate billing for parts of one procedure or treatment. If the NCCI edits permit a CPT code to be billed as part of a procedure, it is a separate and unrelated question whether the MPR formula applies. As noted in response to the question above, the exceptions to the MPR formula in N.J.A.C. 11:3-29.4(f) do not apply to ASC s. CMS publishes an annual list of procedures performed in ASC s and whether they are subject to the MPR formula. These lists are found as Appendix AA in the Final Changes ASC regulations (CMS-1504-FC for 2011, CMS-1414-FC for 2010, etc.) on the CMS website at: [See Auto Medical Fee Schedule Frequently Asked Questions.] Regarding the exclusions of N.J.A.C. 11:3-29.4(f)(2), it is clear that they do not apply to ASCs. Nevertheless, as the foregoing questions and answers bring to light, there are occasions when the exceptions to the MPR formula found in CMS annual list of procedures performed in ASCs apply to such centers. A review of CMS Final ASC Covered Surgical Procedures for CY 2010 (Including Surgical Procedures for Which Payment is Packaged) on the CMS website reveals that CPT code was exempted from application of the MPR formula for the 2010 calendar year. As such, pursuant to DOBI s directive, claimant is entitled to reimbursement for each of the 3 levels at the same amount. I note that respondent cited to my award in Pain & Surgery Ambulatory Center & Surgery Anesthesia Associates a/s/o Bhavana Suri-Mallick v. GEICO Ins. Co., FA (Nat l Arb. Forum Feb. 21, 2012) for the proposition that the MPR formula applies to ASCs. However, the issue of whether the MPR formula applies to CPT code was not before me. Instead, the question presented for my consideration was whether the MPR formula applied to manipulations under anesthesia to the shoulder billed as CPT code when performed with manipulation of the spine, any region, billed as CPT code That is not the situation here and, moreover, claimant never claimed that CPT code is considered an exception to the MPR formula by CMS. This brings me to the amount of reimbursement. Claimant is seeking reimbursement of $2, for each injection for a total of $8, based upon the ASC Facility Fee Schedule for an ASC Group NJ Page 5 of 12

6 Number 5 in the North. Indisputably, CPT code has not been assigned an ASC Facility Fee Group Number. For that reason, N.J.A.C. 11:3-29.4(o) applies. N.J.A.C. 11:3-29.4(o) provides, in pertinent part, as follows: ASC facility fee group numbers are indicated by CPT code on the physician s fee schedule, subchapter Appendix, Exhibit 1. The facility fees for each ASC group are listed in subchapter Appendix, Exhibit 7. If a procedure can be performed in an ASC but it is not listed in the physician s fee schedule, the ASC facility fee for the procedure shall be the fee group in Appendix, Exhibit 7 that includes procedures similar to the unlisted procedure. For example, if an injection code is not included in subchapter Appendix, Exhibit 7, the facility fee for the procedure would be the same as for other injection codes that have a group number. Applying this regulatory provision, respondent argues that CPT code is similar to other injection codes such as CPT codes 62310, 62311, 62318, and 62319, which are assigned ASC Group Number 1. In fact, as respondent correctly points out, the allowable fees for these similar injection codes are very close to what is allowed for CPT code For example, CPT code for a lumbar epidural injection is allowed $1, under the fee schedule. Similarly, CPT code for a lumbar discography injection is allowed $1, Because CPT code is similar to other injections, I agree with respondent that the ASC Group Number 1 fee of $1, applies. Accordingly, I award claimant reimbursement of $3, for the 3 injections on 04/09/10 billed as CPT code Medical Necessity of Platelet Rich Plasma (PRP) Injection It is also respondent s position that claimant has failed to establish the medical necessity of the 05/17/10 injection of platelet rich plasma (PRP) billed under CPT code This issue was specifically addressed by DRP Carro in Northern NJ Ortho Specialists a/s/o R.Q. v. N.J. Mfrs. Ins. Group, FA (Nat l Arb. Forum April 2, 2012) in which he found as relevant the following facts: With respect to the medical necessity issue involving the PRP injection, Respondent had initially denied the procedure which was billed under an unlisted procedure code as not sufficiently documented in the medical record. In response, Claimant sent a letter dated 8/9/10 indicating where exactly in the operative report the PRP procedure was identified. Claimant later submitted a letter dated 11/21/10 again identifying where in the operative report the PRP was described. Dr. Cohen specifically stated, at the end of the procedure, I also did inject platelet rich protein to help inject the platelet rich growth factor for the patient through code Respondent maintains its denial on the basis that nowhere in the operative report or in either of Dr. Cohen s letters does he document or explain the medical necessity of the PRP injection. After stating the applicable regulatory provisions and legal principles, DRP Carro came to the following conclusion: NJ Page 6 of 12

7 Applying these standards to the case at hand, it is hereby determined that Claimant has not established the medical necessity of the PRP injection. There is no dispute that the injection was administered. However, Dr. Cohen never explains why it was necessary or how it was expected to aid the patient. Accordingly, this claim is denied and the unbundling issue over the PRP injection is not reached. In light of DRP Carro s decision, it logically follows that claimant is not entitled to reimbursement for the PRP injection on 05/17/10. Accordingly, I need not address the appropriate Group Number rate for the injection. Obviously, I need not address the unbundling issue. CPT code For the 05/17/10 date of service, claimant billed CPT code together with CPT code the primary procedure. CPT code is defined in the Manual as transpedicular approach with decompression of spinal cord, equine and/or nerve root(s) (eg herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc). Respondent reimbursed claim $5, for CPT code based upon the Group Number 9 fee. The Manual defines CPT code as an [u]nlisted procedure, spine. Claimant billed for 2 levels even though the surgery was performed at only 1 level, as DRP Carro s award in Northern NJ Ortho Specialists confirms. That said, I agree with respondent that the MPR formula applies to CPT code as claimant has not shown that this code is listed as an exception to the MPR formula by CMS. In fact, claimant s counsel in the Northern NJ Ortho Specialists arbitration, as reflected in a 04/03/12 letter sent to him by respondent s counsel, agreed that a modification request relative to the applicability of the MPR formula to CPT code was unnecessary as the formula applied to the surgery charges of 05/17/10. Consequently, I conclude that claimant is entitled to reimbursement for CPT code in the amount of $2, for 1 level. I deny reimbursement for level 2 as unsupported by the Operative Report. In view of the conclusion reached by DRP Carro in Northern NJ Ortho Specialists that annuloplasty was correctly billed as CPT code 22899, respondent withdrew its argument relative to the improper billing of CPT code CPTs code and In addition to billing CPT code for the 05/17/10 date of service, claimant also billed CPT code 63057, which the Manual defines as each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure). Based upon the proofs presented, I conclude that billing for CPT code is unsupported by the Operative Report. Internal Appeals Process (IAP) NJ Page 7 of 12

8 Regarding the discography procedure of 04/09/10, it is respondent s position that claimant lacks standing to proceed as it failed to submit an appeal prior to initiating arbitration as required under respondent s DOBI approved Decision Point Review Plan (DPRP). To begin with, an insurer s DPRP shall include [a]n internal appeals procedure that permits the provider to provide additional information and have a rapid review of a decision to modify or deny reimbursement for a treatment or the administration of a test.... N.J.A.C. 11:3-4.7(c)(6). Furthermore, a DPRP shall include [r]easonable restrictions on the assignment of benefits pursuant to N.J.A.C. 11:3-4.9(a).... N.J.A.C. 11:3-4.7(c)(7). In Coal. for Quality Health Care v. N.J. Dept. of Banking & Ins., 348 N.J. Super. 272, (App. Div. 2002), the court upheld the approval by the Department of Banking and Insurance (DOBI) of insurers policy provisions that imposed reasonable restrictions on assignment of PIP benefits to providers. As to what constitutes reasonableness, the court relied on N.J.A.C. 11:3-4.9, which specifically states that [i]nsurers may file for approval policy forms that include reasonable procedures for restrictions on the assignment of [PIP] benefits, consistent with the efficient administration of the coverage. This regulatory provision provides: Reasonable restrictions may include, but are not limited to: 1. A requirement that as a condition of assignment, the provider agrees to follow the requirements of the insurer s decision point review plan for making decision point review and precertification requests; 2. A requirement that as a condition of assignment, the provider shall hold the insured harmless for penalty co-payments imposed by the insurer based on the provider s failure to follow the requirements of the insurer s [DPRP]; and/or 3. A requirement as a condition of assignment, the provider agrees to submit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5. Additionally, N.J.A.C. 11:3-4.7(d)(8) requires that informational materials for policy holders, injured persons and providers shall include [a]n explanation of the alternatives available to the provider if reimbursement for a proposed treatment, diagnostic test or durable medical requirement is denied or modified, including the insurer s internal appeals process and how to use it.... DOBI has recently clarified the use of the IAP. In Bulletin No , the Commissioner reiterated that an insurer may require a provider to comply with its IAP prior to filing a Demand for Arbitration. Specifically, the Commissioner, among other things, stated: It is only reasonable and logical for insurers to require that, before using the expensive and lengthy external dispute process, an insured or a provider under assignment should first utilize the internal appeals process.... Thus, where a provider agrees in an Assignment of Benefits to follow the requirements of the Decision Point Review plan, the provider also agrees to comply with the insurer s internal appeals process contained therein, and with any penalties imposed in the plan for failure to comply with the internal appeals process. NJ Page 8 of 12

9 Here, patient assigned to claimant his right to receive PIP benefits. By doing so, respondent argues that claimant agreed to be subject to the DPRP requirements and in failing to comply with the internal appeals process in its DPRP prior to filing the Demand for Arbitration, the Assignment of Benefits (AOB) executed by patient was rendered null and void, thereby depriving claimant of standing relative to the 04/09/10 date of service. It is respondent s position that claimant failed to adequately submit an appeal prior to filing for arbitration. The proofs show that claimant was aware of respondent s DPRP requirements. Indeed, the Explanation of PIP Benefits (EOB) sent to claimant provides: IMPORTANT! PLEASE READ! Unless emergent relief is sought, the health care provider must utilize the reconsideration and appeals process prior to filing arbitration and litigation. Information on this process and other requirements are included in NJM s Decision Point Review Plan Requirements, which may be obtained at or by contacting a Claims Representative. The proofs also show that on 02/17/11 prior to the filing of arbitration on 03/28/11 claimant appealed the non-payment of the bill for the services provided on 04/09/10. The appeal, in relevant part, states: We have sent our bill to you for our patient/insured... for the date of service [04/09/10]. Unfortunately, we have not received any answer from you as of this date. The New Jersey Personal Injury Protection Statute requires that the insurer make payment for a covered loss within sixty (60) days of receipt of the bill. Please be advised that this letter serves you as a Formal Appeal. Therefore, if we do not receive a response from you regarding the status of this claim within this week we will put it through Arbitration. Please contact the Collection Department as soon as possible regarding the status of the bill. You may do so telephonically, by fax or by mail. In a 02/25/11 letter, claimant was notified by respondent as follows: Please be advised that your request for a Second Look is deficient. Request for reconsideration and appeals must be submitted 21 days prior to initiating arbitration unless emergent relief is sought, and must specify the issues in dispute and be accompanied by supporting documentation. A copy of respondent s DPRP was attached to the letter. It contains a provision, which requires a health care provider that has accepted an assignment of benefits from the insured/patient to file an internal appeal of any dispute prior to filing for arbitration. More specifically, the DPRP requirements, in relevant part, provide: NJ Page 9 of 12

10 Reconsideration and Appeals Process If treatment, diagnostic testing or durable medical equipment is not authorized, you may request reconsideration by the Physician making the initial determination or, in his/her absence, another designated Physician by submitting a written request with reasons and supporting documentation within 30 days of receipt of a written denial or modification. Submission of information identical to the initial material submitted in support of the request shall not be accepted as a request for reconsideration. Provided that additional necessary medical information has been submitted, a response to the reconsideration request shall be made within fourteen days. If it is determined that peer review or an Independent Medical Examination is appropriate, this information will be communicated within fourteen days as well. Please note that any treating provider who has accepted an assignment of benefits must complete the Reconsideration and Appeals Process prior to initiating arbitration or litigation. For disputes on issues other than requests for decision point review and precertification, any treating provider who has accepted an assignment of benefits must submit a written request for Reconsideration and Appeals specifying the issues in dispute accompanied by supporting documentation at least 21 days prior to initiating arbitration or litigation Furthermore, the DPRP contains additional language regarding appeals as follows: Assignment of Benefits If you wish to be paid directly by us for covered services, you must obtain an executed assignment of benefits. This assignment agreement must be furnished to us upon request. As a condition of assignment, you must follow the requirements of this Decision Point Review Plan and shall hold the insured harmless for penalty copayments imposed by us based on your failure to follow the requirements of the Decision Point Review Plan. Failure to comply with (1) our Decision Point Review Plan Requirements or (2) the requirement to follow the Reconsideration and Appeals Process prior to initiating arbitration or litigation will render any prior assignment of benefits under the policy null and void. In light of the proofs, I find unavailing respondent s argument that patient s AOB is void as to the 04/09/10 date of service. This is a billing dispute. Indisputably, the appeal was filed at least 21 days prior to initiating arbitration. Additionally, even though the DPRP requires that the issues be specified and accompanied by supporting documentation, claimant did not have to specify the issues for respondent s benefit, as they are reflected in the Explanation Codes in respondent s EOB. And, as to supporting documentation, respondent has not explained what supporting documentation it expected to receive from claimant a secondary provider that may have changed its position denying payment. What s more, no evidence has been presented that claimant possessed new or additional documentation to support reimbursement of its bill, which it withheld from respondent. NJ Page 10 of 12

11 Lastly, in support of its position that the appeal was proper, claimant submitted numerous arbitration awards, which I have reviewed. Overall, I find them persuasive. Counsel Fees and Costs Claimant s counsel seeks counsel fees in the amount of $2, together with costs of $ Respondent s counsel objects to such an award with particular opposition to both the total number of hours billed (8.0) and the hourly billing rate ($325.00). It is respondent counsel s position that the counsel fee requested is excessive and not consonant with the amount at issue. In N.J. Coal. of Quality Health Care Prof ls, Inc. v. N.J. Dept. of Banking & Ins. 323 N.J. Super. 207 (App. Div. 1999), the court noted that an award of counsel fees to an insured who successfully obtains an arbitration award against an insurance carrier for payment of PIP benefits... has been the statutory and historical jurisprudence of our State. The courts have construed Rule 4:42-9(a)(6), which allows for an award of counsel fees in an action upon a liability or indemnity policy of insurance in favor of a successful claimant, to permit an award of attorney s fees and judicial actions brought under the PIP statute. I find the claimant was successful and is entitled to an award of counsel fees. In Enright v. Lubow, 215 N.J. Super. 306 (App. Div. 1987) the court identified the factors to be considered in deciding whether to award attorney s fees, including the insurer s good faith in refusing to pay the claim, the excessiveness of plaintiff s demands, the bona fides of the parties, the insurer s justification in litigating the issues, the insurer s conduct as it contributes substantially to the need for litigation, the general conduct of the parties, and the totality of the circumstances. As the court pointed out in Scullion v. State Farm Ins. Co., 345 N.J. Super. 431 (App. Div. 2001), while the Enright factors are to be considered in making the threshold determination as to whether to award counsel fees, many of those factors are equally applicable in determining the amount of counsel fees to be awarded. The court in Scullion clearly suggests that the proper determination of the amount of counsel fees to be awarded requires a line by line analysis of the various certifications of services to determine whether hours expended by counsel or excessive for what appeared to be routine efforts. I have carefully reviewed the line item entries in the PIP Arbitration Attorney Fee Certification submitted by claimant s counsel. In doing so, I have applied the principle set forth in Litton Indus., Inc. v. IMO Indus., Inc., 200 N.J. 372 (2009) for determining the lodestar for legal fees as well as for determining whether it should be enhanced or reduced. I have also carefully considered the arguments advanced by counsel. I am mindful of the fact that any amount awarded as counsel fees must be consonant with the amount at issue and that claimant was only partially successful in this action. I find that an award of counsel fees in the amount of $1,500 is consonant with the amount at issue and consistent with the requisites of R.P.C. 1.5 as well as with the degree of effort, expertise and experience required for a successful prosecution of this claim. I also award costs in an amount of $ NJ Page 11 of 12

12 Therefore, the DRP ORDERS: 1. Medical Expense Benefits: Awarded: Disposition of Claims Submitted Medical Provider Amount Claimed Amount Awarded Payable To Bergen Ambulatory Surgery Center $29, $6, Bergen Ambulatory Surgery Center 2. Income Continuation Benefits: Not in issue 3. Essential Services Benefits: Not in issue 4. Death or Funeral Expense Benefits: Not in issue 5. Interest: I find that the Claimant did prevail. Interest is awatrded pursuant to N.J.S.A. 39:6A-5h.: Interest shall be calculated by respondent Attorney s Fees and Costs I find that the Claimant did not prevail and I award no costs and fees. I find that the Claimant prevailed and I award the following costs and fees (payable to Claimant s attorney unless otherwise indicated) pursuant to N.J.S.A. 39:6A-5.2g: Costs: $ Attorney s Fees: $ 1,500 THIS AWARD is rendered in full satisfaction of all claims and issues presented in the arbitration proceeding. Entered in the State of New Jersey Date: 06/26/12 NJ Page 12 of 12