Key Takeaway
New York court ruling demonstrates how healthcare providers can lose no-fault claims due to verification failures and fee schedule violations in insurance disputes.
Healthcare providers submitting claims under New York’s no-fault insurance system face strict compliance requirements that can make or break their reimbursement cases. Two critical areas where providers frequently stumble involve responding to additional verification requests within mandated timeframes and adhering to established fee schedules.
The Crystal Acupuncture case illustrates how courts handle these common disputes. When insurance companies deny claims based on incomplete verification or fee schedule violations, providers must present compelling evidence to overcome these defenses. This case demonstrates the challenges providers face when trying to establish that they properly responded to verification requests or that their billing amounts comply with applicable fee schedules.
Understanding these requirements is essential for healthcare providers operating within New York’s no-fault system, as procedural missteps can result in complete claim denials regardless of the underlying medical necessity of services provided.
Jason Tenenbaum’s Analysis:
Crystal Acupuncture, P.C. v Travelers Ins., 2019 NY Slip Op 52055(U)(App. Term 2d Dept. 2019)
“With respect to the branches of defendant’s cross motion which sought summary judgment dismissing so much of the complaint as sought to recover upon the claims in the amounts of $281.98, $140.99, $422.97, and $140.99, which claims defendant had denied on the [*2]ground that plaintiff had failed to provide requested verification within 120 days of the initial verification requests (see 11 NYCRR 65-3.5 ), defendant demonstrated, prima facie, that it had not received all of the requested verification. Plaintiff failed to raise a triable issue of fact to rebut defendant’s showing.
“With respect to the branches of defendant’s cross motion seeking summary judgment dismissing the unpaid portion of claims which had sought the sums of $1,452.90 and $1,281.91, which defendant had denied on the ground that the amount sought exceeded the amount permitted by the workers’ compensation fee schedule, defendant’s proof was sufficient to establish that defendant had properly paid those claims pursuant to the workers’ compensation fee schedule. In opposition, plaintiff’s affidavit failed to raise a triable issue of fact with respect to those branches of defendant’s cross motion.”
Key Takeaway
This decision reinforces two fundamental principles in no-fault litigation: insurance companies can successfully defend claims by proving non-receipt of verification materials within the 120-day deadline, and providers cannot recover amounts exceeding applicable fee schedules. Healthcare providers must maintain detailed records of their verification responses and ensure billing compliance with established fee schedules to avoid claim denials.
