Healthcare Litigation Support for Providers

When a date is close: a denial received in the last 30 days (interest pauses if you do not act; that is not a filing deadline), an award mailed in the last 21 days (the master arbitration window), a written verification request nearing its 120-day limit, or an EUO request. Also when bills are overdue with no answer, or the same denial ground keeps coming back. Bring the bills, the assignments and every letter; the dates decide the options.

The amount payable on each valid bill, generally at the fee-schedule rate; interest at 2% per month, figured pro rata, while the bill is overdue, which stops if you do not file within 30 days of a denial; the $40 arbitration filing fee if you prevail; and an attorney’s fee paid by the insurer, generally 20% of the benefits plus interest up to $1,360 per applicant per proceeding. Nothing is guaranteed: the defenses, the policy limits and your records decide the amount.

Proof of claim sent more than 45 days after the service with no documented reason; a missing or defective assignment; charges above the fee schedule without a recognized exception, which can also remove the insurer-paid attorney’s fee; written verification requests unanswered past 120 days; asking the patient for more than the authorized charges (Insurance Law 5108(c)); and licensing gaps, because a provider that fails an applicable licensing requirement is not eligible for reimbursement (65-3.16(a)(12)). Each is a payment rule, not a technicality.

You can, but your testimony becomes part of the insurer’s file and may be used later in arbitration or court. An EUO request must rest on objective standards and be held at a reasonably convenient time and place (11 NYCRR 65-3.5(e)). Robert M. Bott, our Managing No-Fault Attorney, represents medical providers at insurers’ examinations under oath, and we go through the documents with you beforehand. Our EUO page explains the process.

For each patient: the assignment; the application (NF-2) if you have it; each bill with proof of its mailing or transmission date; notes, test results and reports supporting each service; verification requests and your dated replies; EUO and examination notices, transcripts and reports; denial forms with the date received; payments and explanations. Keep them by claim, because the rules generally require all supporting documents with an arbitration request.

The rules set steps, not a total: conciliation up to 60 days; the insurer’s 30 days, plus 30 on request, to respond; a hearing within 45 days of transmittal on request if you filed within 90 days; the award within 30 days after the hearing or final papers; a master arbitration request within 21 days of its mailing, otherwise payment within 30 days. A master arbitrator is to decide within 90 days after assignment. Court actions follow the court’s schedule.

Yes, with a properly executed assignment of benefits on the NF-3, NF-4, NF-5 or the prescribed NF-AOB form, or an authorization to pay benefits; the insurer then pays the provider directly (11 NYCRR 65-3.11). An assignment cannot be revoked unilaterally for services already rendered; an authorization to pay benefits is different and does not transfer the patient’s rights. Keep the original: the insurer may ask for it in writing.

A provider may not demand or request any payment in addition to the charges authorized under Insurance Law 5108, which ties charges to the fee schedules unless an insurer or arbitrator finds unusual procedures or unique circumstances justify more (5108(a), (c)). Whether a patient can be billed in other situations, such as exhausted benefits or a coverage denial, depends on the facts. Ask before sending a patient a bill.

Yes. Under 11 NYCRR 65-3.16(a)(12), a provider is not eligible for reimbursement if it fails to meet any applicable New York State or local licensing requirement needed to perform the service, or the licensing requirement of another state where the service is performed. Insurers can raise eligibility as a defense, so keep licensing and ownership records current and ready to produce.