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.
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 Workers’ Compensation Board & NYCRR 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.
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
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.
Industry Engagement & 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
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