The power of the certified medical coder

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 question of who can provide competent evidence about fee schedule application has significant implications for how these cases are litigated and resolved.

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. Certified medical coders typically hold credentials from organizations such as the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA), demonstrating their expertise in translating medical services into standardized codes and applying appropriate fee schedules.

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. In no-fault cases, when medical services are not covered by the no-fault fee schedule, insurers often apply the workers’ compensation fee schedule as established by the Superintendent of Financial Services. Disputes frequently arise about whether this alternative fee schedule was correctly applied.

A recent Appellate Term 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.

Case Background

LVOV Acupuncture, P.C. provided medical services to an individual injured in a motor vehicle accident and sought reimbursement from Nationwide Insurance Company under New York’s no-fault system. Nationwide paid the claims but reduced the amounts, applying the workers’ compensation fee schedule to determine appropriate reimbursement levels. The plaintiff challenged these reductions, arguing that Nationwide had improperly calculated the allowable amounts.

Nationwide moved for summary judgment, supporting its motion with an affidavit from a certified medical coder. This affidavit explained the methodology used to apply the workers’ compensation fee schedule to the plaintiff’s claims and demonstrated that the reimbursement amounts were calculated correctly. The plaintiff opposed the motion but failed to submit contrary expert evidence challenging the coder’s analysis.

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 ).”

Legal Significance

The Appellate Term’s decision in LVOV Acupuncture establishes that certified medical coders can provide competent expert evidence regarding fee schedule application in no-fault litigation. This represents an important development in evidentiary standards for these cases. Previously, parties might have questioned whether a medical coder’s affidavit alone could establish proper fee schedule application, or whether additional expert testimony from physicians or other medical professionals was required.

The court cited Quality Comprehensive Medical Care, P.C. v New York Central Mutual Fire Insurance Co., 65 Misc 3d 143, and Sama Physical Therapy, P.C. v American Transit Insurance Co., 53 Misc 3d 129, as precedents supporting the use of certified medical coder affidavits in fee schedule disputes. These cases collectively establish that courts will accept the specialized expertise of certified coders when evaluating whether insurers correctly applied fee schedules to determine reimbursement amounts.

This evidentiary standard makes practical sense given the technical nature of medical coding and fee schedule application. Certified medical coders undergo extensive training specifically focused on these issues, often making them more qualified than physicians to address the purely administrative question of whether a fee schedule was correctly applied. Physicians excel at clinical judgments, while coders specialize in the translation of clinical services into billing codes and the application of payment methodologies.

The decision also demonstrates the importance of proper affidavit execution. The court emphasized that the affidavit was “executed by defendant’s certified medical coder,” suggesting that the coder’s professional credentials and the affidavit’s compliance with procedural requirements were both essential to its acceptance as evidence.

Practical Implications for Attorneys and Litigants

For insurance companies defending fee schedule challenges, this decision provides a cost-effective litigation strategy. Rather than retaining expensive medical experts to testify about billing issues, insurers can rely on affidavits from certified medical coders who are typically less expensive and more readily available. This can significantly reduce the cost of defending summary judgment motions in fee schedule disputes.

However, insurers must ensure that their coders are properly credentialed and that the affidavits adequately explain the methodology used to apply the fee schedule. The affidavit should detail which codes were assigned to which services, how the fee schedule was accessed and interpreted, and how the final reimbursement amounts were calculated. Conclusory statements without supporting analysis are unlikely to satisfy the insurer’s burden on summary judgment.

For healthcare providers challenging fee schedule reductions, this decision highlights the importance of retaining contrary expert evidence. When an insurer submits a certified medical coder’s affidavit supporting its reductions, the provider cannot simply argue that the coder is wrong without presenting competing expert evidence. Providers should consider retaining their own certified medical coders to review the insurer’s calculations and identify any errors or misapplications of the fee schedule.

The decision also serves as a reminder about the burden of proof in these cases. Once the insurer submits competent evidence that the fee schedule was correctly applied, the burden shifts to the provider to raise a triable issue of fact. General objections or arguments unsupported by expert evidence will not suffice to defeat summary judgment.

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.

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