At Tangent We specialize in No-Fault Billing & Collection
No-Fault billing has proven to be one of the most complex niches of medical billing. Since most medical billing companies do not specialize in No-Fault billing, they are unaware of its complexities. Healthcare providers who are brave enough to accept No-Fault insurance as a method of payment often face many difficulties in getting paid for their services.
No-Fault medical billing requires the use of special forms, adherence to government requirements, specific time limitations, and special mailing instructions. These, along with other intricate billing processes, are only the tip of the iceberg when it comes to No-Fault billing.
Automobile insurance companies work hard not to pay the healthcare provider. Meanwhile, they are declaring record numbers in annual profits. The fact is, insurance companies are doing everything they possibly can to ensure the delay or denial of claims for no-fault healthcare services. This results in physicians having to face long delays in payments, cash flow issues, and difficulty sustaining or expanding their practice.
Our Approach to No-Fault Billing, we aim to deliver the very best No-Fault billing service to our clients and prepare them today, to face the challenges of tomorrow.
We addressed the issues of No-Fault billing & collection by breaking down the entire procedure into several components. We have rethought the entire No-Fault medical billing & Collection process from start to finish with cutting-edge yet practical approaches. There is not a single medical billing company in the State of New York which specializes in No-Fault billing & collections, except us.
Tangent-No-Fault-EHR is highly sophisticated and equipped with features needed to take full command of the No-Fault billing process. We left no stone unturned, and made sure to include mail features with 100% valid proof of mail & proof of delivery for each and every date of service, and financial reporting features that are superior to those of any medical billing software ever built.
As a No-Fault specialty billing company, we aim to deliver unique, customized, and sophisticated service packages to deliver the best results to our clients. We built a customized No-Fault Billing software andreinvented No-Fault billing from the ground up.
We invite you to browse through our website and read about what we have to offer. Remember, a complimentary consultation with a No-Fault billing expert is only a phone call away at (516)427-5400.
No Fault Billing
At Tangent we specialize in No-Fault billing & Collection. Tangent-No-Fault-EHR is custom designed to deliver real results. Please click on the link below to read more about No-Fault Billing & Collection process.
Following is an outlined Tangent-No-Fault-EHR billing process. We invite you to browse through it all, and if you have questions at anytime, remember that we are only a phone call away.
Step 1 of No-Fault Billing: Producing No-Fault Bills: Physicians have 45 days from the date of treatment to produce and submit No-Fault medical bills to insurance companies. According to the current No-Fault Insurance regulations, all No-Fault medical treatment bills must be created on the prescribed No-Fault Verification of Treatment Form (“NF-3”). Article 28 facility bills must be submitted on the UB-04.
We produce most No-Fault bills using the NF-3. No-Fault medical bills are produced on a daily basis, based on the treatment rendered by the physician. To ensure that all No-Fault medical bills are produced and submitted within 45 days of each date of service, our No-Fault billing software is programmed to follow a 30-day rule. This provides a 15-day window to address unforeseen circumstances, and ensures that No-Fault bills are never submitted late.
Step 2 of No-Fault Billing: No-Fault Billing Review Process: No-Fault bills are created on a daily basis and queued in a “Review Folder.” Physicians can access the bills online using an encrypted connection, which allows them to review and sign the bills and then release them for printing. Most physicians using our No-Fault billing service do this on a weekly basis.
Once the physician reviews the claims, the claims are queued for printing. We then make sure that all necessary notes—for example, trigger point injection and physical therapy notes—are attached to the bills and signed. All NF-3s are printed and are grouped by individual insurance companies.
Step 3 of No-Fault Billing: The Insurance Company’s Response: After we submit a No-Fault claim to an insurance company, the insurance company has 30 days to do one of the following:
1. Pay the bill,
2. Request verification, or
3. Deny the bill.
Insurance Carrier’s Requests for Verification: Insurance companies send requests for verification to help them decide whether or not to pay a certain claim. Usually, insurance companies send out a large number of requests and demand documents they have previously received. Verification requests are rarely legitimate, and in most cases are used as a delay tactic. However effective April 1, 2013, physicians have only 120 days to respond to each verification request by an insurance company (this does not include requests for examinations). Failing to do so within 120 days will result in the complete and final denial of the entire bill.
As we receive verification requests from insurance companies in the mail, they are scanned into Tangent-No-Fault-EHR and indexed to patients’ account. If we are in possession of the documents or information requested, we create a verification response and mail it back to the insurance company. If we are not in possession of the documents or information requested, we request the missing information from the provider, referring physician, or the patient’s attorney. Once we obtain the requested information it is forwarded to the insurance company.
If a document is not within the custody or control of the provider, the provider must submit written proof within 120 days, stating that the document cannot be obtained or does not exist. Failure to submit such proof will result in the complete denial of the bill. If such letter is needed, we prepare it, send it to the provider for signature and then forward it to the insurance company.
Tangent- No-Fault – EHR is designed to complete the verification process within 72 hours. If we are not in possession of the document or information being requested by the insurance carrier, that timeline is extended to another 72 hours. Beyond that, the timeline system is designed to alert the account executive and manager to intervene and ensure that the outstanding verification request is handled efficiently.
The timeline for responding to verification requests is very specific. Once the statutory 120-day period has passed and verification is still pending, no further collection method, like arbitration or litigation, can be engaged on that particular bill. All communication with the insurance company, throughout the life cycle of the claim is preserved with proof of mail and proof of delivery in Tangent-No-Fault-EHR.
Denial of Payment: As we receive denials, each denial is identified by reason and indexed into the patient’s file. Though a denial can be for any specific reason, usually they are for the following reasons;
1. The services that the healthcare provider rendered lacked medical necessity (a determination made on the basis of a negative independent medical examination (“IME”) or a peer review report written by the insurance carrier’s paid doctor);
2. The patient violated his or her No-Fault policy by failing to appear for an IME or examination under oath (“EUO”);
3. The provider failed to appear for an EUO;
4. The services were not billed in accordance with the New York State Workers’ Compensation Medical Fee Schedule; and/or
5. The bill or bills at issue were not timely submitted within 45 days of their respective date or dates of service.
We are experts in No-Fault billing and collection, hence each billing file is prepared with the No-Fault collection’s process in mind. Our customized No-Fault-EHR billing software is designed to keep all documents in an itemized and indexed format. If a claim has received a denial , our No-Fault billing system will automatically move it to the collection stage. A complete “Collection Ready” file will be delivered to the physician’s attorney, via email, FTP, and/or any other preferred method. This process is fully automated.
Collection Ready File: A file delivered to the physician’s attorney typically has the following items:
1. Assignment of Benefit
2. NF-3, The actual No-Fault Bill
3. The physician’s report
4. Medical reports or supporting medical documents
5. Proof of mail
6. Proof of delivery
7. All correspondence with the insurance company (verifications)
8. Proof of mail & delivery for all verifications
9. The actual Denial
To learn more about our unique, customized No-Fault billing process, call (516)427-5400 for an immediate, free consultation.
Proof of Mail & DeliveryNo-Fault insurance is a medical coverage for injuries that are related to motor vehicles. No-Fault is always primary, no matter what other insurance coverage a person may have, in states where car insurance is mandatory.
No-Fault Billing Proof of Mail & Delivery
Many physicians believe that since they are using an (“EMR”) software of some sort, they are and should be 100% paperless. Although this may be the case with most medical insurance companies, this is NOT the case for No-Fault insurance companies in The State of New York. No-Fault insurance companies require that ALL No-Fault bills must be printed and submitted using an NF-3 Form.
All No-Fault medical bills require proof of mailing. The burden is on the physician to prove that his or her No-Fault medical bills were produced and mailed within 45 days of the date of treatment.
When the time came to build the “MAIL” feature of Tangent-No-Fault-EHR billing software, which would generate a solid court-accepted proof of mail, we left no stone unturned. We steered away from old methods like, the use of a mailing book and registered mail with return receipt requested. Instead, we built a highly efficient and effective proof of mail system. We built a customized shipping software, utilizing the laser barcode system, that works in conjunction with each No-Fault bill generated by us, and matches it with the priority mail serial number from the United States Postal Service upon delivery.
A Brief Description of Tangent-No-Fault-EHR Mailing Software
Unique Serial Number: As each bill is created it gets assigned a unique serial number. This is a unique identifier that helps track each bill within our billing system at any given stage. Each bill gets queued for printing within its assigned folder, that folder then gets assigned a United States Postal Service’s Priority Mail tracking number.
The United States Postal Service’s Priority Mail Service: As bills from each folder are printed, they are matched with the United States Postal Service’s Priority Mail Label, combining the unique serial number and United States Postal Service’s Priority Mail tracking number.
All bills are then asserted in the priority mail envelope and mailed to the insurance carrier. Upon delivery, Tangent-No-Fault-EHR billing system’s shipping software works directly with the United States Postal Service’s Priority Mail Service, to retrieve the proof of delivery. The entire process is automated and seamlessly integrated into our No-Fault billing system.
This produces the most powerful Proof of Mail and Proof of Delivery, a signed document, on the United States Postal Service Letterhead, confirming the delivery of a specified piece of mail. The receipt includes the time at which the insurance company received the mail, the name and signature of the person who received the mail. The mailing receipt also includes a tracking number assigned by the U.S. Postal Service. This tracking number syncs directly into our No-Fault billing software. The software automatically links the tracking number to all the sent claims in that folder, and to the first and last dates of service indicated on that claim.
Tangent-No-Fault-EHR Proof Of Mail & Proof Of Delivery Includes:
- Patient’s name.
- Dates of treatment that were billed and mailed.
- Billed amount.
- Address of the insurance company or claims office that the bills were mailed to.
- Insurance company’s claim number.
- Date the bills were mailed.
- Name and Signature of the a person who received the bills at the insurance company.
- Time and date at which those bills were received.
- Tracking number linked to each individual bill.
Our customized No-Fault mailing feature provides proof of mail, as well as proof of delivery for each and every single bill produced and mailed by us. We are experts in No-Fault billing and collection. For more information about our state-of-the-art proof of mail system, call us at (516)427-5400 for an immediate, free consultation.
No Fault IMEThe purpose of an IME is for the insurance company to verify, by having its own doctor examine the patient, that the services provided for the injured party were medically necessary; additionally, IMEs can be used for the purpose of determining whether or not medical benefits for the injured party will continue.
What is an Independent Medical Examination (IME)?
Whenever any person puts his or her mental or physical condition at issue in any case which compensation is sought, insurance companies have the right to have a physician of its own choice to examine the client. Normally, insurance companies accomplish this by obtaining what is known as an IME, which is a medical examination of the patient that is conducted by a doctor who is paid by the insurance company to conduct the examination.
Generally, the IME is scheduled by agreement of both parties; however, if the injured party does not cooperate, the insurance company may seek a court order requiring the patient to attend the IME. The insurance company will send a letter to the injured party indicating the date, time, and specialty of the doctor who will perform the IME, along with any requests for medical records that the insurance company is entitled to ask the patient to bring with him or her to the IME.
The purpose of an IME is for the insurance company to verify, by having its own doctor examine the patient, that the services provided for the injured party were medically necessary; additionally, IMEs can be used for the purpose of determining whether or not medical benefits for the injured party will continue. After the IME is conducted, the doctor puts together a report, called an “IME Report,” and submits the report to the insurance company to review. The report generally contains the doctor’s findings during the examination, and whether or not in the doctor’s opinion, the medical services in question were medically necessary.
What Happens at an IME?
IME examinations are cursory at best. Doctors performing IMEs make thousands of dollars conducting these examinations for insurance companies, yet most examinations last anywhere from 5 – 10 minutes, and are generally limited to the following:
· Completion of a medical-history form by the patient
· A review of available documents provided by the treating physician
· A brief medical exam
· Recording of doctor’s opinions and impressions of the patient.
The Law and IMEs
After an insurance company receives a claim from a medical provider whether orally or in writing, the insurance company has a right to “additional verification” before it determines whether it is going to pay or deny the claim. Insurance companies must request verification not once, but TWICE, before it is able to deny a claim. Therefore, if the requested verification is not complied with by the medical provider the first time, before the insurance company denies the claim, it must issue a second request for the verification. If that second request is not complied with, then the insurance company may deny the claim.
According to New York insurance regulations, insurers are entitled to IMEs as “additional verification” following the receipt of a medical provider’s claim forms; this verification process works to rule out any potential fraudulent claims. All medical examinations requested by the insurer are held at a place and time reasonably convenient to the patient, and the patient will be reimbursed for any loss of earnings and reasonable transportation expenses incurred in complying with the request.
If after the IME, the insurance company denies the claim, this does NOT mean that the treating medical provider must stop treatment, or that there will be no payment for services. If the patient’s symptoms remain, and it is the opinion of the treating physician that medical treatment is warranted, then medical treatment should be continued. After an IME denial, medical treatment can still be rendered, and all bills can be litigated or arbitrated. 97.5% of IME denials DO NOT hold up in court or arbitration, and the insurance companies are required to pay the treating physicians.
Since the doctors are paid by insurance companies to conduct this “independent” medical examination, it is hard to believe that these examinations are in fact “independent” of what the insurance companies are claiming to be medically necessary. At AMSAC, we ensure that every denial based on the results of an IME made by an insurance company is opposed, and we specialize in collection of these denials based on IME. AMSAC has successfully collected on thousands of IME denials.
Please note that is very important to save all IME denials received in the mail from insurance companies. At AMSAC, we specialize in collection for medical treatment rendered after an IME denial, and you can be sure that all documentation received in the mail is automatically attached to the patient’s billing account within 72 hours.
What Happens if the Injured Patient does not Attend the Scheduled IME?
Technically, when a patient fails to comply with an insurer’s reasonable request for an IME, that person has failed to meet a condition precedent for No-Fault coverage and therefore, any pending claim submitted for services rendered may be denied due to the policy breach.
To be clear, an insurer CANNOT issue a denial after one IME no-show. Insurers also may not issue a denial based on an first-time IME no-show, and then tell the insured that it will take back the denial after the patient shows up to the second IME. The insurer must wait until the patient fails to attend two IMEs before it denies the claim. Remember, a demand for an IME is a verification request, which means there must be 2 requests before an insurer is allowed to deny a claim.
Steven Fogel Psychological, P.C. v. Progressive Cas. Ins. Co. is the lead case on IME no-shows in New York as of 2006. Before Steven Fogel, the rule was that the earliest date that insurance companies were permitted to cut off benefits based on IME no-show, is the date of the SECOND no-show. In other words, benefits could not be cut off retroactively. In 2006, the Court concluded that an insurer may deny a claim retroactively to the date of loss for a claimant’s failure to attend IMEs when, and as often as, the insurer may reasonably require. But even Steven Fogel does not give insurance companies a rock-solid basis for automatically denying claims.
The Insurance Department is clear in an opinion letter dated 2/14/05 in stating that if a patient fails to show up for an IME twice, but offers a reasonable excuse for not attending the examinations, and is attempting to establish (in cooperation with the No-Fault insurer) a reasonably convenient time to attend, then insurance companies must wait to deny the claim.
Excuses that have been found to be reasonable are the following (this list is not exhaustive):
- IME was scheduled at an inconvenient time or an inconvenient place
- Work or school schedules conflict with the scheduled IME
- Family emergencies
- Bad weather
In other words, Courts tend to be liberal in excusing the IME no-show if the patient shows that he is attempting to cooperate with the insurance company in rescheduling another appointment, and is acting in good faith.
How do I know that the IME is being Fairly Conducted?
A doctor who is paid by an insurance company to conduct a medical examination of a party who is adverse to the insurance company, to determine whether or not the insurance company should pay or deny a claim made by the medical provider, seems awfully questionable. Many times questions are raised as to how the medical provider knows that the IME is being conducted fairly. How do we know if the insurance company doctor is truly reporting what the patient is saying? How do we know that the doctor is doing a true thorough examination?
Doctors are required to rise to their standard of professional ethics; however, to be certain, patients ARE legally allowed to record the IME themselves. Tape recorders, use of an extra witness during the exam, and even video cameras have been used.
Medical providers rest assure, 97.5% of IME denials are NOT upheld in litigation or arbitration, and here at AMSAC, we pride ourselves on exceeding that standard.
No Fault Peer ReviewA physician paid by an insurance company reviews and analyzes the patient’s medical reports. During a peer review, a physician paid by an insurance company reviews and analyzes the medical records written by a patient’s treating physician.
What Is a Peer Review?
During a peer review, a physician paid by an insurance company reviews and analyzes the medical records written by a patient’s treating physician. This review is conducted so that an insurance company can determine whether services the treating physician rendered to his or her patient were medically necessary.
If the peer review concludes that a certain service was not medically necessary, the insurance company can deny payment of that service. Peer reviews are supposed to be impartial. Nevertheless, because peer reviewers are paid by insurance companies to determine whether a claim should be denied, they are hardly ever that.
What Happens During a Peer Review?
Unlike an independent medical examination (“IME”), a peer review does not entail a medical examination of the patient. The patient does not have to visit the peer reviewer’s office and does not have to submit to any examinations.
What happens is that an insurance company selects a physician of its choice, and pays him or her to review the treatment records of a certain patient. After reviewing these documents, the peer reviewer creates a “Peer Review Report,” and submits it to the insurance company. Usually, the report will contain the peer reviewer’s medical opinions as to whether the services the treating physician rendered were medically necessary to treat the patient’s injuries.
The Law and Peer Reviews
According to Regulation 68, insurance companies are entitled to conduct a peer review as additional verification of a no-fault claim. If the peer review report concludes that the services rendered were not medically necessary (which it will likely do), the insurance company then has a basis to deny the claim based on lack of medical necessity.
However, this does not mean that the medical provider should cease treatment of the patient. If patients continue to experience symptoms, the medical provider should continue treatment. Medical providers should not cease treatment based on a ten-minute review of medical reports conducted by a biased physician.
If the reason for a no-fault claim denial is a negative peer review report, the insurance company must release a copy of that report to the patient, his or her attorney, and/or his or her treating physician upon request of any of these parties.
Claims denied based on peer reviews can be litigated or arbitrated. To establish a viable denial on the grounds of medical necessity, an insurance company must show that the peer review report “set[s] forth a sufficiently detailed factual basis and medical rationale for the claim’s rejection.”
97.5% of denials that are based on peer reviews do not hold up in court or arbitration, and insurance companies are required to pay the treating physician’s claims.
Physician’s Right to Rebut Peer Reviews
Once an insurance company’s physician performs a peer review, the question of medical necessity does not immediately end. A patient’s treating physician can challenge the peer review by writing a rebuttal or by having a third-party physician perform his or her own peer review. Peer review rebuttals raise an issue of fact as to whether services rendered were medically necessary, and thus increase the treating physician’s likelihood of success in litigating the denied claims.
When an insurance company issues a denial based on a peer review, we oppose the denial and use our no-fault expertise to collect on those claims. We have successfully collected on thousands of claims that were denied based on the results of a peer review.
Please note that it is very important for healthcare providers to save all denials based on the results of a peer review sent by insurance companies. Our clients can be sure that all documents from insurance companies, especially denials, are automatically attached to the patient’s billing account within 72 hours of receipt.
Medical providers can rest assured that 97.5% of denials based on peer reviews are not upheld in litigation or arbitration. Here at Tangent, we pride ourselves on exceeding that standard.
 Amaze Medical Supply v. Eagle Ins. Co., 2 Misc.3d 128.
No Fault CollectionIn our aim to deliver unique no fault billing services to our clients, our no-fault team will recommend the best strategy to fight insurance carriers’ improper and arbitrary denials.
In our aim to deliver unique no fault billing services to our clients, our no-fault team will recommend the best strategy to fight insurance carriers’ improper and arbitrary denials.
The New York State Insurance Law provides healthcare practitioners with two options to recover disputed or denied bills for services rendered to injured claimants.
Disputes with insurance carriers can either be submitted to arbitration or be filed in civil court. Either case, we will work with the healthcare provider and their collection attorney to determine which approach will maximize your recovery and obtain the results you desire.
Our No Fault Billing system is designed to keep the collection in mind from the very start. As experts in no fault billing, we make sure that from the very beginning medical bills are submitted to auto insurance companies correctly.
All bills are mailed in timely manner, with all supporting documentation, with proof of mail and proof of delivery. We electronically document all correspondence with the insurance companies. We respond to all verifications requests by the insurance company while securing a proof of mail and proof of delivery.
Our system is designed to keep track of this procedure in a seamless and automated manner. Once we have complied with all outstanding verification requests by the insurance carrier and claim is determined to be ripe for collection it is automatically moved to a collection status.
Claim is then moved to healthcare provider’s collection attorney. This includes the entire file with all necessary documentation required by the collections attorney. We have the ability to deliver a complete Arbitration Ready or Litigation Ready file to any attorney who has been retained by the healthcare provider. That attorney will receive the entire file electronically in his/her preferred format.
We also offer a monitoring service; this includes keeping a track of how long it takes for healthcare provider’s attorney to actually file an arbitration or litigation.
Physician / Patient EUOAccording to the No-Fault Regulations, an insurance company may demand, as a condition to no-fault coverage, that an applicant for benefits appear at an examination under oath (“EUO”).
No Fault Physician EUO
According to the No-Fault Regulations, an insurance company may demand, as a condition to no-fault coverage, that an applicant for benefits appear at an examination under oath (“EUO”). By accepting a patient’s assignment of benefits, a healthcare provider stands in the shoes of his or her patient and is subject to many of the same conditions and obligations, including responding to a request for an EUO. (See “Assignment of Benefits.”)
Physician EUOs are often made in conjunction with an insurance company’s investigation into the corporate structure of the healthcare provider. However, the scope of an EUO is not limited to that. A physician EUO can be prompted for many other reasons (e.g., billing practices, reasons for deciding on a particular method of treatment, etc.).
The nature of an EUO is very similar to a deposition. During an EUO, a physician is questioned about his or her practice under oath and the testimony is recorded by a court reporter.
Often, the EUO request is accompanied by document demands. These documents can be as simple as the treating physician’s credentials, and as complex as his or her financial records. Insurance companies like to ask for anything and everything under the sun when it come to physician EUOs. Therefore, physiciansshould seek advice from an attorney prior to attending an EUO and/or turning over any documentation.
An Insurance Company’s Right to Demand an EUO of a Physician
An insurance company’s demand that a healthcare provider appear for an EUO is an extraordinary means to verify a no-fault claim. While an insurance company has the right to demand this verification, its right is not unrestrained.
It is well-settled that an insurance company must demonstrate a reasonable basis for conducting an EUO. Furthermore, the Superintendent’s regulations “demand that carriers delay the payment of claims to pursue investigations solely for good cause.”
An insurance company’s reasonable basis or good cause for demanding an EUO must be based upon the application of specific facts and objective standards. These standards are subject to review by the Department of Financial Services.
Unfortunately, both the Department of Financial Services and the courts have largely determined that an insurance company is under no obligation to disclose its reason for demanding an EUO during the verification. Therefore, usually, the reasonableness of the EUO demand cannot be challenged until the claim is submitted to arbitration or litigation.
Mallela and Corporate Status Verifications
The rights and obligations of insurance companies and providers in relation to a physician EUO request are the subject of vigorous contention. Insurance companies have notoriously abused their right to conduct physician EUOs as a way to defeat otherwise indefensible claims and/or discourage healthcare providers from accepting its insured.
In order to understand what a corporate status verification is, it is necessary to have a basic understanding of both the Business Corporation Law (“BCL”) and the No-Fault Law. To summarize, BCL § 1503 states in substance that each shareholder, director, and officer of a professional corporation must be authorized by law to practice the profession that the corporation is being organized to practice. For example, if a corporation is formed for a medical practice, all shareholders of that corporation must be physicians. If a non-physician is also a shareholder, then that corporation is not legally organized.
This law was directly incorporated into No-Fault Law in 2002 when Regulation 11 N.Y.C.C.R. § 65-3.16(a)(12) was enacted. It provided in pertinent part that a “provider of healthcare services is not eligible for reimbursement under 5102(a)(1) of the Insurance Law if the provider fails to meet any applicable New York State or local licensing requirement.”
Following the promulgation of the regulation, it was clear that if a professional corporation was not in compliance with the BCL, it was not eligible for reimbursement under No-Fault. But who had the right to question whether a provider was properly incorporated? Could an insurance company withhold payment from a provider it suspected as being fraudulently incorporated? Could an insurance company demand cooperation from a provider it suspected of being controlled by a layman?
These issues were presented before the Court of Appeals in the seminal case of State Farm Mut. Auto. Ins. Co. v. Mallela.
In Mallela, the Court held that insurance companies can withhold reimbursement from fraudulently licensed medical corporations. Furthermore, insurance companies were entitled to “look beyond the face of licensing documents to identify willful and material failure to abide by state and local law.” As such, even if a medical corporation is properly incorporated, an insurance company is entitled to investigate further if it suspects that a layman is improperly influencing that practice.
Subsequent to the Mallela decision, insurance companies have turned their investigatory privilege into a vehicle for delay and recalcitrance. Unlike a verification that is specific to an individual claim, a Mallela verification is global and encompasses all claims submitted by the provider. Once an insurance company unilaterally determines it has good cause to investigate a provider’s licensing credentials, it can withhold all payments to that provider, regardless of the patient’s medical needs. Finally, if the provider is not compliant with reasonable requests associated with the investigation, the insurance company can assert a potentially insurmountable defense to payment.
Healthcare Providers Subject to an EUO Request
The rights and obligations of healthcare providers and insurance companies in the context of verifications by physician EUOs are complex and ever-changing as new court decisions are rendered and new regulations are promulgated.
What course of action a healthcare provider should take is largely dependent on the facts and circumstances surrounding the nature of the specific verification. What you must know is that if your practice bills no-fault to any significant degree, it is almost certain that an insurance company will demand a physician EUO. Sadly and contrary to warnings by the Court of Appeals, abuses of the corporate status verification process have gone largely unregulated. Once a physician EUO is requested, it is essential that your practice be represented by counsel through all stages of the verification.
No Fault Patient EUO
During an examination under oath (“EUO”), an insurance company requests that a patient appear before an attorney and/or an investigator to answer questions under oath relating to a no-fault claim.
The patient, who is entitled to representation by an attorney at the EUO, can be questioned about a range of topics. These topics include, but are not limited to, prior injuries, circumstances surrounding the accident, his or her present medical condition, and treatment. Usually, by the time the EUO is conducted, the insurance company has already received bills from the patient’s treating physician, and will question the patient as to whether they received the same treatment as those reflected in the billing.
An insurance company has the right to demand an EUO of the patient as a means to verify a no-fault claim. This right was given to insurance companies in the revised No-Fault Regulations of 2002, which state that “[u]pon request by [an insurance company], the eligible injured person or that person’s assignee or representative shall . . . as may reasonably be required submit to examination under oath by any person named by the [insurance company] and subscribe same.”
Scheduling of an Examination Under Oath
There are various provisions within the No-Fault Law that an insurance company must follow when scheduling an EUO of a patient. Proper mailing of the notice is often an issue of contention. However, it should be noted that insurance companies are under no obligation to advise a treating physician that an EUO of the patient is scheduled.
The content of the letters is critical as well. An EUO must be scheduled for a time and in a place and location that is reasonably convenient for the patient. Specifically, proper scheduling letters should:
- Give the patient at least two weeks’ notice of the EUO date;
- Set the EUO at a place within the same county in which the patient resides; and
- Apprise the patient that he or she is entitled to be reimbursed for reasonable transportation costs and lost earnings incurred due to his or her attendance.
Additionally, because insurance companies must request verification of a claim not once but twice before denying that claim, an insurance company is obligated to provide a patient with two opportunities to attend an EUO. That is, if a patient fails to appear for the first EUO, an insurance company has an obligation to schedule a second appearance. If the patient fails to appear for the second scheduled EUO, an insurance company then has the right to deny the claim.
Consequences for Failure to Attend an EUO
It is well-settled that a patient’s unexcused failure to comply with a demand for an EUO (i.e., failure to attend two properly scheduled EUOs) is a policy violation and grounds for an insurance company’s disclaimer of the patient’s no-fault benefits.
Because an EUO is a form of verification and is deemed received on the date of the “missed EUO,” the insurance company should deny the claim within thirty days of the patient’s failure to appear for the second EUO.
Consequences for Treating Physicians
It is important that a physician understand that if his or her patient fails to appear for two properly scheduled EUOs, an insurance company may have grounds to deny a claim retroactively to the date of loss. In some jurisdictions, an insurance company is even allowed to amend a previous denial and/or assert an otherwise late denial to include the defense of missed EUOs.
A patient’s missed EUOs is often fatal to the treating physician’s claim for reimbursement. Unfortunately and unfairly, scenarios arise where a physician provides medically necessary treatment to a car accident victim, and otherwise abides by the No-Fault Regulations, only to have his or her claim denied due to circumstances beyond his or her control.
We strongly advise our clients to educate their patients on the importance of responding to an insurance company’s reasonable EUO request.
Furthermore, to reduce the consequences of a patient’s failure to attend an EUO, we provide our clients with medical lien agreements. A medical lien allows a medical provider to seek direct payment from his or her patient (and/or from the settlement of the patient’s personal injury lawsuit) when a patient’s no-fault benefits are cut off due to a policy violation.
Upon the intake process at our clients’ offices, patients will be required to sign a medical lien. In that way, the patient acknowledges our client’s right to receive payment if the patient violates his or her no-fault policy.f
No Fault LitigationOur vast knowledge and experience with No-Fault ensures our clients the best service in collecting their unpaid claims. We recognize the individual needs of each client and support staff work together striving for the best result on behalf of our clients.
In our aim to deliver unique, customized, and sophisticated service packages to our clients, our team of experts will find the best strategy to fight against insurance carriers’ improper and arbitrary denials. The New York State Insurance Law provides healthcare practitioners with two options to recover money for services rendered to injured claimants. Disputes with insurance carriers can either be submitted to AAA arbitration or be filed in court.
We work with physicians and their attorneys to determine which approach will maximize their recovery and obtain the best results.
The Advantages of Litigation
Unlike arbitration, litigation requires that the parties in a lawsuit follow the Rules of Evidence and Procedure. This requirement often works to the disadvantage of insurance carriers and dramatically decreases the likelihood of their success in litigation. As a result, insurance carriers are more inclined to settle claims in advance of trial for higher numbers.
Disadvantages of Litigation
The biggest disadvantage of the litigation in no-fault collections currently is the delay of time. There are so many no-fault collection claims pending in civil court throughout New York that it may be 3 to 4 years before a final trial date arrives.
The second disadvantage is cost, the initial filing fee, if a no-fault collection case makes it to the final trial date, the cost associated could be around $ 210.00 dollars for each claim. Whereas in arbitration this cost is only $ 40.00 dollars
The Process of Litigation
To begin litigating a no-fault claim, the healthcare provider-plaintiff files a summons and complaint with the clerk of a court with competent jurisdiction to hear the matter. (The court chosen often depends on the facts of each case as well as the amount in dispute.) The summons and complaint is also served on the defendant-insurance carrier, putting it on notice of the pending litigation.
To successfully recover in a no-fault matter, the provider must establish a prima facie case. Although courts have differing opinions of the evidentiary standard that a provider must satisfy to establish a prima facie case, a provider is often required to show that it timely mailed statutory claim forms to the insurance carrier and that payment of no-fault benefits is overdue.
Typically, a provider will submit the following with its summons and complaint:
1, A statutory claim form, NF-3, NF-5
2, The bill or bills for the services it rendered;
3, An assignment of benefits (“AOB”) form; and
4, Proof of mailing of the claim or claims.
After summons and complaint are filed and served, the parties will go through the process of discovery, in which the parties exchange evidence, request answers to interrogatories, and take depositions. Subsequently, a Notice of Trial (or Note of Issue) will be filed, signifying that discovery is complete.
Insurers will use multiple stages of litigation to dismiss the case or delay the resolution of the matter. For example, after a Notice of Trial is filed, insurers will often file summary judgment motions to argue that:
1, The services that the healthcare provider rendered lacked medical necessity (a determination made on the basis of a negative independent medical examination (“IME”) or peer review report written by the insurance carrier’s paid doctor);
2, The patient violated his or her no-fault policy by failing to appear for an IME or examination under oath (“EUO”);
3, The provider failed to appear for an EUO;
4, The services were not billed in accordance with the New York State Workers’ Compensation Medical Fee Schedule; and/or
5, The bill or bills at issue were not timely submitted within 45 days of their respective date or dates of service.
If, after motion practice, the insurance carrier refuses to settle or offers a settlement amount that is unacceptable to the physician, the case may go to trial.
Service we offer:
We are experts in No fault billing and collection, hence each billing file is prepared with the no-fault collection’s process in mind. Our customized no-fault billing software is designed to keep all documents in an itemized and indexed format. If litigation is the venue for choice for a physician, our no fault billing system will prepare the file as it moves through the stages of billing, verifications, and denials.
We deliver a complete “Litigation Ready” file to physician’s attorney, via email, FTP, and or any other preferred method.
Litigation Ready File: Litigation ready file delivered to the physician’s attorney typically has the following items:
1, Assignment of Benefit
2, NF-3, The actual No-Fault Bill
3, The physician’s report
4, Medical reports or supporting medical documents
5, Proof of mail
6, Proof of delivery
7, All correspondence with the insurance company (verifications)
8, Proof of mail & delivery for all verifications
9, The actual Denial
Throughout all stages of litigation—and especially at trial—we provide full assistance and cooperation to physician’s collection’s attorney. If there are issues that an insurance carrier may raise to keep the physician from recovering money, we will assist the collection’s attorney to be the best of our ability.
You are entitled to recover money for the medical services you render to your patients. To learn more from us about how we can help facilitate in no fault litigation please call (516) 427-5400 for an immediate, free consultation.
No Fault ArbitrationThe New York State Insurance Department designated the American Arbitration Association (“AAA”) to administer the no-fault arbitration process in the State of New York. The AAA must follow specific guidelines to arbitrate a no-fault dispute.
In our aim to deliver unique, customized, and sophisticated service packages to our clients, our team will find the best strategy to fight against insurance carriers’ improper and arbitrary denials. The New York State Insurance Law provides healthcare practitioners with two options to recover money for services rendered to injured claimants. Disputes with insurance carriers can either be submitted to AAA arbitration or be filed in court.
We work with physicians and their attorneys to determine which approach will maximize their recovery and obtain the best results.
The Advantages of Arbitration
Generally, arbitration is less costly and time consuming than litigating a matter. Because the relaxed treatment of evidentiary rules in arbitration gives a slight advantage to insurance carriers presenting their defense, an arbitration is usually recommended if no dispute regarding the validity of the carrier’s claim process exists. In any event, the healthcare provider should make a cost/benefit analysis to determine whether litigation or arbitration is the best way to resolve the dispute.
The Process of Arbitration
The New York State Insurance Department designated the American Arbitration Association (“AAA”) to administer the no-fault arbitration process in the State of New York. The AAA must follow specific guidelines to arbitrate a no-fault dispute.
Filing A Claim with AAA
Generally An AAA arbitration filing includes:
1, A denial of claim (“NF-10”) form, with all fields completed;
2, An AAA form AR, with all questions answered (in the absence of an NF-10);
3, All bills in dispute;
4, The Assignment of Benefits (“AOB”) form; and
5, Any other information the applicant will rely upon at an arbitration hearing, should the hearing be necessary.
The filing should be sent to AAA, and a complete copy should also be sent to the insurance carrier. Any evidence the applicant submits after this initial filing will be marked as a late submission. The arbitrator then has the discretion of whether to consider this evidence.
Before an arbitration hearing, the case goes through a conciliation process. During this process, a conciliator assigned to the case contacts each party in an effort to save time and money by resolving the dispute without the need for a hearing. Any offers of settlement are made through the conciliator. Many cases filed for arbitration are resolved during this process.
Within 30 days of receiving notification from AAA of the applicant’s request for arbitration, an insurance carrier is required to submit all documents in support of its denial of the claims in dispute. Any evidence submitted beyond the 30-day period will be marked as a late submission and might not be considered by the arbitrator during hearing.
The AAA will mail a Notice of Hearing to each party at least 15 days prior to the hearing date. An arbitrator will be randomly assigned to hear the case and AAA case managers will provide administrative support throughout the arbitration process.
After a hearing is conducted and closed, an arbitrator writes a decision (the “award”) and delivers it within 30 days of the hearing’s closing. This award can be modified upon written application of a party within 21 days of delivery.
A party can appeal an award within 21 days of the award’s delivery. Accompanying a copy of the award, the party appealing will submit a letter outlining the grounds for appeal.
Service we offer:
We are experts in No fault billing and collection, hence each billing file is prepared with the no-fault collection’s process in mind. Our customized no-fault billing software is designed to keep all documents in an itemized and indexed format. If Arbitration is the venue for choice for a physician, our no fault billing system will prepare the file as it moves through the stages of billing, verifications, and denials.
We deliver a complete “Arbitration Ready” file to physician’s attorney, via email, FTP, and or any other preferred method.
Arbitration Ready File: Litigation ready file delivered to the physician’s attorney typically has the following items:
1, Assignment of Benefit
2, NF-3, The actual No-Fault Bill
3, The physician’s report
4, Medical reports or supporting medical documents
5, Proof of mail
6, Proof of delivery
7, All correspondence with the insurance company (verifications)
8, Proof of mail & delivery for all verifications
9, The actual Denial
Throughout all stages of Arbitration we provide full assistance and cooperation to physician’s collection’s attorney. If there are issues that an insurance carrier may raise to keep the physician from recovering money, we will assist the collection’s attorney to be the best of our ability.
You are entitled to recover money for the medical services you render to your patients. To learn more from us about No-Fault Arbitration, please call (516) 427-5400 for an immediate, free consultation.
- Account Receivables Team
- Claim Management Team
- Payement Posting
Denial Management Team