Key Takeaway
Court ruling demonstrates how certified medical coders can establish proper fee schedule application in New York no-fault insurance disputes through expert affidavits.
In New York no-fault insurance disputes, establishing the correct reimbursement amount often hinges on proper application of fee schedules. Insurance companies frequently challenge medical providers’ billing, arguing that services were overcharged or incorrectly coded. When these disputes reach court, the testimony and documentation from qualified professionals becomes crucial evidence.
The role of certified medical coders has become increasingly important in these proceedings. These professionals possess specialized knowledge of medical coding systems, billing procedures, and fee schedule regulations. Their expertise can be particularly valuable in complex cases involving specific procedure codes or when determining appropriate reimbursement rates under New York’s workers’ compensation fee schedule framework.
A recent appellate decision highlights just how powerful the testimony of a certified medical coder can be in resolving billing disputes and establishing that proper procedures were followed in determining reimbursement amounts.
Jason Tenenbaum’s Analysis:
LVOV Acupuncture, P.C. v Nationwide Ins. Co., 2020 NY Slip Op 51339(U)(App. Term 2d Dept. 2020)
“the affidavit executed by defendant’s certified medical coder, submitted in support of defendant’s motion, established that defendant had properly used the workers’ compensation fee schedule to determine the amount which plaintiff was entitled to receive for the services in question (see Quality Comprehensive Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co., 65 Misc 3d 143, 2019 NY Slip Op 51734 ; see also Sama Physical Therapy, P.C. v American Tr. Ins. Co., 53 Misc 3d 129, 2016 NY Slip Op 51359 ).”
Key Takeaway
This decision demonstrates that a properly executed affidavit from a certified medical coder can serve as compelling evidence in no-fault insurance disputes. The court accepted the coder’s expertise as sufficient proof that the insurance company correctly applied the workers’ compensation fee schedule, showing how professional credentials and detailed documentation can resolve complex billing disagreements.
