No Fault -Independent Medical Examinations (IME's)

Can you ask for another IME from your  no fault insurance carrier ?

Yes. You can call your No Fault insurance claims representative and  request another IME.  Demand it.Explain why you are not satisfied with the outcome when your No Fault benefits are cutoff. I have known patients to do this and successfully get another exam set up.  Not all requests are answered with a yes. It depends on your carrier and how well you address your complaint. I hear it all the time of a 5 minute exam or less where there is almost no conversation between the Independent Medical Examination physician and the patient regarding the injuries that were sustained in the MVA and the treatment that still needs to continue. The IME physician works for the insurance carrier. They are not your treating physician. They are paid for an opinion and the carrier often stands on that opinion.

I have denials routinely come in on a patient's treatment claims this year - due to an IME that happened last year. This patient made enough phone calls to his carrier that when I call to ask for a payment reconsideration on a denied insurance claim, they do so and without hesitation.

You can open the door to more treatment if you boldly and firmly make your requests known to the insurance carrier claim representative. Don't stay silent on a treatment issue. This is about your health and getting the continued treatment you need.

30 Days to Pay or Deny a No Fault Medical Insurance Claim - How to File A Complaint

Information for Healthcare Providers

No Fault insurance carriers have a responsibility to pay a medical treatment claim that is without issue in 30 days time from receipt of the claim . Make sure you keep an official record of mailing proof - whether it be certified mailing or claims mailed out on all your no fault patients in a mailbook log officially date stamped by your local post office.

 Don't get comfortable with the numerous delay tactics sent out by insurance carriers. When you are told by the insurance claim rep. in a sweet, calm tone that  "the claim was processed and the check is in the mail" ... for two months straight-  it is time to file your official written complaint.

 I actually communicate on a regular basis with one particular carrier who refuses to pay any claim sent in -until they hear from me via the New York State Department of Financial Services .  When I have sent everything in twice -by mail and fax and made my follow up phone call to the carrier - in which there is never a written or verbal response given - I file a complaint online requesting assistance for this claim to now be paid with interest. I attach all my proof to the complaint sent in . Thanks to today's technology, The Department of Financial Services gets my online complaint to the insurance carrier the same day. My phone rings from the carrier  later that same day for me to finally hear the spoken words, " Hey Julie, I got your message today. "  :*)  This is how we communicate. This is how I get the claim paid . It is a sad truth, but truth nonetheless and I am very thankful that the majority of complaints I filed this year with The Department of Financial Services were rapidly and successfully  handled.    (JP)

Click link below to file a complaint at the Department of Financial Services.

Complaint Link


You can file a No Fault, Workers Compensation or Prompt Pay Complaint  using our Online Complaint Form. You will receive immediate confirmation and be assigned a file number.
You will have one hour to process the complaint form. If you do not complete the form within one hour you will be prompted to refresh and the information you have entered before refreshing will be lost.
The form will contain a series of questions. If you do not understand any of the requested information, you can click on the question and a help box will appear to offer an additional description.

The costs of copying records is the responsibility of the health service provider.

 

No Fault Verification Requests For Copies Of Medical Records

Please click link for full article found at The Department of Financial Services.

 

Question Presented:

When a health service provider has submitted a bill to an automobile insurer for No-Fault insurance benefits, after receiving an assignment of benefits from an eligible injured person, and the insurer delays payment of the bill pending receipt of requested verification of the of the claim, is the health service provider responsible for reproduction costs incurred in providing the verification?

 

 

Conclusion:

 

Yes.

The eligible injured person's application for No-Fault benefits and all documentation and information provided to the insurer are components of the required "written proof of claim". The obligation to supply the "written proof of claim" consistently remains with the party claiming No-Fault benefits. Accordingly, the obligation to bear the costs of copying records to comply with a verification request will always remain with the eligible injured person or assignee health service provider.

If you are injured on a bus or a school bus in New York State...

 

NF-2 Form Reference

 

 

NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must  be paid by your auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further  provides that you should only file a No-Fault claim with the insurer of the bus or school bus if there is no such auto policy in your household.   **The above rule does not apply and you may file a No-Fault claim with the insurer of the bus or school bus if  you are the operator, owner or employee of the owner of the bus company.

Coding Topic : Handling denials with Modifier 24 and 25

 

Modifier 24- Definition Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: Physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.

An E/M service can be coded with modifier 24 to indicate a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is not valid when coded with surgeries or other types of services. It is not appropriate for modifier 24 to be coded with diagnostic tests performed in the postoperative period. These are not part of the global surgical allowance and are always considered separately.
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How to handle denials on No Fault claims submitted with Modifier 24 and 25

 Telephone Appeal

 Written Appeal-

 If payment is still not made - then arbitrate.

Modifier 24 - Telephone appeals to the insurance carriers are common for such denials and usually effective . Diagnosis codes are often overlooked by the insurance carrier  as well as the modifier when billing is submitted with a modifier 24 .  Explain to the insurance  claim representative what denial was placed on the claim, why the denial is incorrect and request payment reconsideration to be made.  If this doesn't get the payment in , then submit a payment review request in writing, with a copy of the AMA modifier 24 guidelines ,pointing out how the E/M service billed is not related to the surgery performed. 
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Modifier 25- Definition

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

***Use the same steps as above - Telephone appeal, written appeal and arbitrate if necessary .


Billing and Collections staff should have modifier appeal letters on hand to respond to this type of denial immediately. 

Radiology~Denial Issue ...Lack of medical necessity

Insurance Denies Radiology claims as not medically necessary

 

 

 

Read below which is found at the link above  that helps explain the differences between authorization to pay and assignment of benefits.  This information also mentions what actions can follow when a denial is placed on a claim as not medically necessary.

STATE OF NEW YORK
INSURANCE DEPARTMENT25 BEAVER STREET
NEW YORK, NEW YORK 10004

George E. Pataki Governor

Gregory V. Serio Superintendent

The Office of General Counsel issued the following opinion on February 18, 2003, representing the position of the New York State Insurance Department.

RE: Assignments & Authorizations to Pay No-Fault Benefits

Question Presented:

When a provider of health services has submitted a bill to a No-Fault insurer for payment for health services rendered, and wishes to bill such patient for the services when the insurer denies the bill based upon the lack of medical necessity for performing such services, by what method can the provider reserve the right to bill their patient for the services rendered?

Conclusion:

A No-Fault health service provider may reserve the right to bill their patient (eligible injured person) for health services provided, when the No-Fault insurer denies payment for medically unnecessary services rendered through the use of an authorization, executed by the eligible injured person to their No-Fault insurer, to make payments of benefits directly to the health service provider.

Please also click below link for another article addressing the same issue.

Provider has the right to bill the patient when the denial states "not medically necessary".
 

Facts:

The inquirer, a radiology facility, which sometimes renders health services to patients covered under the No-Fault system, accepts assignments of No-Fault benefits from eligible patients prior to performing MRI tests. Such patients are advised that they will be responsible for making direct payment of the bill for services rendered to the inquirer, after the inquirer has submitted claims to the No-Fault insurer, in the event that the insurer denies payment based upon a determination of lack of medical necessity for the services performed. The inquirer indicated that it did not wish to assume responsibility for submitting denials of claims to arbitration in order to resolve the payment disputes. The inquirer asked how it could retain the right to bill the patient when reimbursement by the insurer has been denied under these circumstances.

ANALYSIS

In order to address the inquiry, it is necessary to recognize the distinction made between an assignment of No-Fault benefits ("Assignment") from an eligible injured person (the patient) to their provider of health services, and an authorization by the patient ("Authorization") to their No-Fault insurer to pay benefits directly to their provider of health services, under the Department No-Fault Regulation 68.

Pursuant to N.Y. Comp. Codes R. & Regs. tit. 11, � 65-3.11(b) (First Amendment to Regulation 68) (2003), entitled "Direct payments":

(b) In order for a health care provider/hospital to receive direct payment from the insurer, the health care provider or hospital must submit to the insurer:

(1) a properly executed Authorization to Pay Benefits as contained on NYS Forms NF-3, NF-4 or NF-5 or other claim form acceptable to the insurer. Execution of an authorization to pay benefits shall not constitute or operate as a transfer of all rights from the eligible injured person to the provider; or

(2) a properly executed assignment on:

(i) the prescribed Verification of Treatment by Attending Physician or Other Provider of Service form (NYS Form NF-3): or

(ii) the prescribed Verification of Hospital Treatment form (NYS Form NF-4), or the prescribed Hospital Facility form (NYS Form NF-5): or

(iii) the prescribed No-Fault Assignment of Benefits form (NYS Form NF-AOB contained in Appendix 13 or an equivalent form containing non-substantive enhancements, but no changes may be made to the assignment language itself.

An agreement to accept either an Assignment or Authorization is always voluntary on the part of a No-Fault provider. A provider may require payment from their patient at the time that services are performed. However, if the patient and provider agree to an assignment of benefits, they must use the prescribed assignment language that appears in the above-referenced forms as required by Regulation 68. Specifically, the mandatory assignment language assigns to the health care provider "all rights, privileges and remedies to payment for health care services provided…under Article 51…." Further, the health provider states that they will not pursue payment directly from the patient after receiving a denial based upon a lack of medical necessity unless the assignment is revoked by the provider based upon the assignor patient’s lack of coverage and/or violation of a policy condition due to the actions or conduct of the patient.

The effect of acceptance of an assignment of benefits by a health provider is that by accepting the transfer of the right to receive benefits, which were available directly to the eligible injured party, the health provider also assumes the right to, and responsibility for, pursuing available remedies when claims are denied, since the assignee provider now stands in the shoes of the eligible injured person. Therefore, after an assignment has been effected, an assignee provider, who has submitted a claim for services rendered, must be the party to request and pursue arbitration when the claim has been denied.

The rights and obligations imposed under an assignment of benefits do not exist under an Authorization to Pay Benefits form, which is executed by the eligible injured person. The optional authorization language in NYS Forms NF-3, NF-4 and NF-5 state: "I authorize payment of health benefits to the undersigned health care provider or supplier of services described below. I retain all rights, privileges and remedies to which I am entitled under Article 51 (the No-Fault provision) of the Insurance Law." (Emphasis added).

Under either an Assignment or Authorization, a patient is not required to pay their health service provider at the time that services are rendered. As stated above, while an Assignment serves to transfer all rights, privileges and remedies from the patient to the provider, no such transfer occurs under an Authorization. An authorization is no more than direction from an eligible injured person to their No-Fault insurer to send reimbursement directly to their health provider. Accordingly, if an Authorization is used, the provider retains the right to bill the patient directly when a denial has been issued for lack of medical necessity. In addition, unlike an assignment, where the right to dispute a denial through arbitration is transferred to the provider, the patient executing an authorization retains the right to dispute a denial.

The inquirer’s facility does not wish to assume responsibility for pursuing arbitration to resolve disputed claims, and wishes to retain the right to bill the patient directly when a denial has been issued for lack of medical necessity. The appropriate instrument in such instance would be an execution by its patient of an authorization to pay benefits. Under these circumstances, the patient can exercise its right to arbitration to resolve any dispute concerning the medical necessity of services rendered.

For further information you may contact Supervising Attorney Lawrence M. Fuchsberg at the New York City Office.

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Reimbursement Tip:  Detailed documentation provided to an insurance  carrier as to why an MRI /CT scan are ordered for a patient, helps reduces denial scenarios. Today , a prescription, the physician's examination notes and a detailed letter of medical necessity fully stating all  the medical reasons why the scan is being ordered  are sent out with the bill on the initial submission of a claim. If the reasons are truly done in the best interest of the patient and make a difference in the  patient's treatment plan, then payment should be made for the scans done. There are guidelines and articles set forth stating when an MRI/CT scan should be performed. If the guidelines aren't followed and documentation is found lacking, expect a denial instead of payment.  Peer review denials done at the request of the insurance carrier ,usually list their article source, sometimes including the full article to back their reasons why payment of the scan done and billed for - should be disallowed.

 

Changes to No Fault as of 4/1/13 - 4th Amendment to 11 NYCRR 65-3

http://www.dfs.ny.gov/insurance/r_finala/2013/rf68ca4t.pdf

NEW YORK STATE

DEPARTMENT OF FINANCIAL SERVICES

FOURTH AMENDMENT TO 11 NYCRR 65-3

(INSURANCE REGULATION 68-C)

CLAIMS FOR PERSONAL INJURY PROTECTION BENEFITS

 

Please click on the above link to  better understand the importance of submitting correct billing charges  according to the NY No Fault Fee Schedule and how soon you should respond to a carrier's request for additional verification information on a medical claim under review from your practice.

 

Failure to do either one as instructed  in the new amendment can result in non-payment of claims and with no recourse.