N.J. Admin. Code § 13:44E-2.11

Current through Register Vol. 56, No. 21, November 4, 2024

Section 13:44E-2.11 - Overutilization; excessive fees

(a) A licensee shall not directly or indirectly engage in the rendering of any bill or the submission of any claim for service that:

1. Is not justified by the needs of the patient;

2. Is for any diagnostic or treatment services, goods or appliances which are excessive in quality or quantity;

3. Represents multiple charges for the same chiropractic services or care, goods or appliances;

4. Contains an excessive fee. A fee is excessive when, after a review of the facts, a licensee of ordinary prudence would be left with a definite and firm conviction that the fee is so high as to be manifestly unconscionable or overreaching under the circumstances. The charging of an excessive fee shall constitute professional misconduct pursuant to 45:1-21. Factors which may be considered in determining whether a fee is excessive include, but are not limited to, the following:

i. The time and effort required;

ii. The novelty and difficulty of the procedure or chiropractic care;

iii. The skill required to perform the procedure or chiropractic care properly;

iv. Any requirements or conditions imposed by the patient or by circumstances;

v. The nature and length of the professional relationship with the patient;

vi. The experience, reputation and ability of the licensee performing the services; and/or

vii. The nature and circumstances under which services are provided;

5. Is for services, goods or appliances which were not rendered or supplied; or

6. Is for a charge or claim which, due to the presence of insurance coverage, exceeds the usual and customary charges for such services, goods or appliances for patients who do not have insurance coverage.

N.J. Admin. Code § 13:44E-2.11

New Rule, R.1994 d.122, effective 3/7/1994.
See: 25 N.J.R. 3937(a), 26 N.J.R. 1231(b).
Recodified from N.J.A.C. 13:44E-2.13 and amended by R.2001 d.257, effective 8/6/2001.
See: 33 N.J.R. 1329(a), 33 N.J.R. 2683(a).
In (a)3, substituted "care" for "treatments"; in (a)4ii and iii, substituted "chiropractic care" for "treatment". Former N.J.A.C. 13:44E-2.11, Right to a hearing, recodified to N.J.A.C. 13:44E-2.10.
Amended by R.2007 d.31, effective 2/20/2007.
See: 38 N.J.R. 3235(a), 39 N.J.R. 656(a).
In the introductory paragraph of (a), substituted "that" for "which"; and in (a)4vii, substituted a semicolon for the period at the end.