PIP / No-Fault Insurance Advisory, Claims Audit & Litigation Support

AJHC Financial Partners provides comprehensive advisory, audit, and litigation support services for Personal Injury Protection (PIP) and No-Fault Bodily Injury insurance matters. We specialize in medical claims review, reimbursement validation, coding compliance, and dispute resolution across highly regulated environments.

INSIGHTS & INTELLIGENCE

Bone Growth & Neuromuscular Stimulation for Soft Tissue Injuries,

Or $5,000 Bone-Growth Devices Prescribed for Sprains and Strains

The Doctor Who Told Me Not to Become One

The Story that Every Physician Should Hear, and Why We Believe the Joy of Medicine Can Be Restored

The DME Twilight Zone,

Or when shell companies, suspicious prescriptions, and bilateral airplane braces fly on the same claim

Wheelchair Cushions for Ambulatory Patients

Or When Walking Patients Require Wheelchair-Exclusive Equipment

Who’s Paying for the Lambo,

Or When a Routine Spinal Injection Claim Looks More Like an Invoice for a Luxury Vehicle

Dissecting DME Invoices: How Questionable Invoices Can Turn into an SIU Field Trip

Manipulation Under Anesthesia (MUA) without the Anesthesia

Or When “Creative Coding” Deserves Its Own Award Category

Our team brings deep expertise in New York No-Fault regulations, Workers’ Compensation fee schedules, and multi-state reimbursement methodologies, supporting insurance carriers, SIU units, TPAs, legal teams, and healthcare providers.

New York: Worker’s Compensation Board & NYCCR regulations
New Jersey: Department of Banking and Insurance (DOBI)
Florida: PIP Statute § 627.736 and Administrative Code
Michigan: No-Fault Act

Pennsylvania: Title 75 § 1797
Texas: Division of Workers’ Compensation (DWC)
California: Tort Law, MedPay and Official Medical Fee Schedule (OMFS)

AJHC Financial Partners provides independent, technically rigorous support across the lifecycle of no-fault (PIP) claims, disputes, and arbitration/litigation. Our work is grounded in a deep understanding of reimbursement methodologies, regulatory frameworks, and evidentiary standards required in arbitration and litigation settings.

Fee Coder Reviews

Medical billing audits designed to validate coding accuracy, clinical documentation support, reimbursement calculation, and regulatory compliance across No-Fault (PIP) and Workers’ Compensation frameworks.

Arbitration/Litigation

Defensible coding analyses, reimbursement validation, expert reports, affidavits, and technical case support to strengthen dispute resolution outcomes for carriers, legal teams, and complex claims environments.

IME/Peer Support

Specialized support for Independent Medical Examiners (IME) and peer review physicians by integrating reimbursement logic, fee schedule methodology, policy language, and billing compliance analysis into clinical reviews.

Adjuster Training

Targeted training programs for adjusters, SIU teams, and claims professionals focused on specialty-specific documentation requirements, billing red flags, reimbursement methodologies, and litigation preparedness.

Industry Expertise & Thought Leadership

AJHC Financial Partners brings extensive experience across No-Fault (PIP) and Workers’ Compensation environments, supporting complex claim reviews, dispute evaluation, and reimbursement validation.

Supported arbitration and litigation matters and reviewed cases for major insurance carriers, including American Transit Insurance Company, National General Insurance Company, Integon Indemnity Corporation, GMAC, Adirondack Insurance Exchange, New South Insurance Company, and Esurance Property and Casualty Insurance Company.
Served as Subject Matter Expert in various panels as unbiased party for claim reviews and dispute analysis involving medical billing, coding, and payment calculations across No-Fault and Workers’ Compensation matters, supporting outcomes across pre-litigation, arbitration, appeals, and litigation.
Active member and Chapter Speaker with the Association of Certified Fraud Examiners (ACFE), specializing in healthcare fraud, regulatory compliance, and No-Fault / Workers’ Compensation frameworks.
Member of the New York Alliance Against Insurance Fraud (NYACT), contributing to industry efforts addressing complex PIP / No-Fault fraud schemes.
Conducted regulatory compliance audits for the New York State Department of Health (NYSDOH), including cost reports, supplemental payments, provider reimbursements, and claims adjudication policies.

Performed internal audits for large healthcare systems and medical groups, verifying billing accuracy and compliance with Workers’ Compensation, Medicare, Medicaid, and commercial payer requirements.

Fee Coder Medical Claims Review & Payment Validation

We conduct detailed, line-by-line audits of medical claims to ensure compliance with applicable regulations and fee schedules, including:

Verification of medical records to ensure documentation supports billed services.
Identification of upcoding, unbundling, duplicate billing, modifier misuse, unlicensed practice, etc
Detection of overpayments, underpayments, and improper denials
Independent reimbursement recalculations aligned with regulatory frameworks
Compliance with No-Fault Fee Schedule and Workers’ Compensation Board guidelines
Medical coding standards, including CPT, HCPCS, ICD-10, and NCCI (National Correct Coding Initiative) guidelines.
State-specific PIP regulations (NY, NJ, FL, MI, PA, TX)
EAPG reimbursement methodologies and outpatient payment logic

Our reviews identify billing irregularities, scope-of-practice violations, overpayments, underpayments, and fee schedule discrepancies while delivering independent reimbursement recalculations aligned with state-specific regulations, coding standards, and payer policies.

Arbitration, Litigation & Expert Support

AJHC supports No-Fault (PIP) and Workers’ Compensation disputes with structured claim reviews, reimbursement validation, and payment analyses developed in alignment with arbitration expectations and industry standards.

Certified experienced coder affidavits and policy expert reports
Arbitration, litigation and appeal support
Case-specific reimbursement analysis
Collaboration with legal counsel to strengthen technical positioning
Expert witness testimony (as applicable)

Our analyses are structured to meet arbitration/ litigation standards and withstand legal scrutiny.

IME / Peer Review Strengthening

We can work directly with Independent Medical Examination (IME) and peer review physicians to enhance the strength and defensibility of their reports by:

Incorporating policy-specific and fee schedule considerations
Aligning clinical opinions with billing, coding, and reimbursement frameworks
Identifying gaps between medical conclusions and claim payment logic
Strengthening documentation for arbitration and litigation

This ensures that medical opinions are not only clinically sound, but also financially and regulatorily defensible.

Adjuster Training & Claim Strategy Development

AJHC provides targeted training for claims adjusters, SIU teams, and claims leadership, focused on improving claim handling accuracy and litigation readiness. Examples include:

What documentation to request by specialty (DME, orthopedics, chiropractic, neurology, pain management, etc.)
- Specialty-specific cheat sheets
- Documentation checklists
- Claim review frameworks
How to evaluate billing patterns and red flags
Understanding fee schedules and reimbursement methodologies
Identifying weak vs strong cases before escalation

Result: stronger claims, reduced leakage, and better arbitration/litigation outcomes.