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.