Key Takeaway
Court ruling shows healthcare providers must specifically address verification requests rather than making general statements about not possessing records.
Additional verification requests are a critical component of New York No-Fault Insurance Law, serving as insurers’ primary tool to validate medical claims and prevent fraud. When healthcare providers receive these requests, their response can make or break their ability to recover payment. The quality and specificity of the response often determines whether a provider has met their legal obligations under the no-fault system.
A recent appellate court decision illustrates the importance of providing targeted, specific responses to verification requests rather than broad, general statements about record availability. This case demonstrates how even well-intentioned responses can fail to satisfy legal requirements when they lack the necessary specificity and directness that courts demand.
Jason Tenenbaum’s Analysis:
Excel Surgery Ctr., L.L.C. v Fiduciary Ins. Co. of Am., 2017 NY Slip Op 50408(U)(App. Term 2d Dept. 2017)
“n response to defendant’s verification requests, plaintiff informed defendant, by letter, that plaintiff was an ambulatory facility and, as such, did “not possess all the medical records,” advising defendant to “request any additional information directly from the treating provider.” Plaintiff’s response did not refer to any specific request or state that plaintiff was not in possession of any of the items requested by defendant. Thus, plaintiff did not demonstrate that it had sufficiently responded to defendant’s verification requests”
So assume Plaintiff said we do not have the exact record? Different result as that would place the case into the Mt. Sinai v. Autoone category.
Key Takeaway
Healthcare providers must respond specifically to each verification request item rather than providing general statements about their record-keeping practices. A blanket response stating you “don’t possess all medical records” without addressing specific requested items will likely be deemed insufficient by the courts. This differs significantly from cases involving additional verification non-receipt where providers explicitly state they don’t possess the exact records requested.
