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NJ Care paths

What the heck are care paths? It sounds like a maze.



So I’m been trying to educate you about how PIP works (see the prior entries for more information), and today I’d like to focus on care paths. Sounds interesting right? YOU ARE WRONG.


The current care paths have been in place since January of 2001:


They refer to different areas of the body commonly complained of following a motor vehicle accident. For example, there are care paths for the cervical spine, which vary in whether they are soft tissue complaints or herniated disc/radiculopathy. Care paths prescribe the treatment an injured person can get, that insurance companies must reasonably pay for (there are other factors that come into play here but this is pretty basic). For example, if your neck hurts (i.e. the cervical spine) you must undergo “conservative treatment” for a period of time.


Depending on what your complaints are following that initial round of conservative treatment 2-4 weeks, you may be eligible for diagnostic testing such as an MRI or EMG. But wait, “if the diagnosis of radiculopathy is obvious and specific on clinical examination, EMG testing is not recommended.” Then, later on, the insurance company for the other party is going to make a big deal about the fact that the client didn’t have an EMG and claim they must not actually have radiculopathy (if only I had a dollar for every time this happened) injury. But I digress off the paths.


As you progress down the paths from conservative treatment, you move towards diagnostic and interventional treatment. After about 3-5 months of conservative treatment, even if it provides temporary relief, the insurance company is going to want to cut you off from that type of treatment. They’ll say that you’ve received treatment beyond what the care paths call for, or that you have plateaued because you aren’t experiencing long-term relief. So they send you for an independent medical examination where usually they determine that you do not need additional treatment in the conservative areas (PT or chiropractic, never both at the same time) so they won’t pay for it anymore. Or they just outright deny it as not medically necessary, which can be appealed through the medical provider for a “medical review” all the way up to a PIP appeal through PIP arbitration.


When you do move into interventional treatment, you are seen by an orthopedic or neurology specialist, usually who recommends that you undergo different types of injections and diagnostic testing. So you see a pain management specialist who in turn advises you of the different injection treatment options based on the symptoms you describe and discuss, along with a review of the testing and prior treatment available. You are never required to undergo that treatment, but it is usually a precursor to any surgical discussions.


If injections are successful, that may be where, on the care paths you stay for a while, receiving as needed injections. If not, you usually are seen by an orthopedic or neurosurgeon who will advise whether you are a candidate for surgical intervention. If yes, and the insurance company approves, you undergo the surgery, and return to conservative treatment through physical therapy for your post-surgical recovery.

At any point in this process the insurance company can deny treatment as not reasonable or medically necessary; seek to have you evaluated by an independent doctor to determine if treatment should continue and then terminate your benefits for that particular specialty.


This can seem counterintuitive to clients who are in pain and discomfort and don’t understand why they have to undergo treatment that is actively causing them pain or is not providing them with relief or diagnostic help. While you are never required to follow the care paths, most doctors who work in the PIP area are aware that in order for them to receive payment, they must follow the care paths, and many clients don’t really ask. They know they are in pain, that they are seeing a medical professional who is trying to help them with the pain, and they don’t really say, “PT is really hurting me, why can’t I have an MRI to make sure it isn’t causing further injury” but rather, go along with the treatment recommendations.


Now from a practical standpoint, you always want to start conservative treatment-wise. No doctor, except for emergencies, should be jumping right to surgery without conservative treatment and appropriate diagnostics. We see this in the non-PIP area as well. I had a family member who was complaining of pain, saw the doctor, who recommended a course of PT to see if that helped the pain, and then had the family member undergo an x-ray, followed by an MRI. But the insurance company wanted to see a specific amount of PT and the x-ray performed before they would approve the MRI.


So that is my explanation on care paths, and why they work the way they do. I hope this provided some education and maybe understanding of why medical treatment post MVA follows the path it does.


Bottom line, it’s complicated, but we at Drinkwater & Goldstein, LLP can help you navigate the care paths maze so you can get the treatment you want and need. See ya next time.


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