Reimbursement of Wrongly Denied Medical Bills – Case Study

Two separate arbitrations were filed by our office for a Chiropractor seeking reimbursement of wrongly denied medical bills for the treatment of an injured patient under the patient’s No-Fault Insurance policy.

The first claim never went to arbitration and was settled for $6,700 (including chiropractic services and testing).

The second claim went to arbitration and the Chiropractor was awarded the full reimbursement of treatments and services $9,788.20 plus interest and attorney’s fees.

Our firm helped this one Chiropractor recover $16,488.20 plus interest and attorneys fees for one patient’s wrongly denied chiropractic treatments.

The arbitrator decided the second claim as follows: “An Applicant establishes its prima facie showing of entitlement to judgment as a matter of law by submitting evidentiary proof that the prescribed statutory billing forms had been mailed, received by the Respondent and that payment of no-fault benefits were overdue. Mary Immaculate Hospital v. Allstate Insurance Company, 5 A.D. 3d 742, 774 N.Y.S. 2d 564 ( 2ndDept. 2004 ). A facially valid claim has been defined as one that sets forth the name of the patient, date of the accident, date of service, description of services rendered, and the charges for those services. ( See, Vinnings Spinal Diagnostic P.C. v. Liberty Mutual Insurance Company,186 Misc. 2d 287; 717 NYS2d 466 )

The burden then shifts to the Respondent to prove that the services were not medically necessary. Amaze Medical Supply a/a/o Bermudez v. Eagle Insurance, 2 Misc. 3d 128 , 784 N.Y.S.2d 918 (2003).

Once the insurer makes a sufficient showing to carry its burden of coming forward with evidence of lack of medical necessity, “ must rebut it or succumb.” ( See, Bedford

Park Med. Practice P.C. v American Transit Tr. Ins. Co., 8 Misc. 3d 1025 (A), 2005, 2005 NY

Slip Op 51282 citing Bauman v Long Island Railroad, 110AD2d 739, 741, ).

As a general rule, reliance on rebuttal documentation will be weighed in light of the documentary proofs and arguments presented at the arbitration. Moreover, the case law is clear that a provider must rebut the conclusions and determinations of the IME doctor with his own facts. Park Slope Medical and Surgical Supply, Inc. v. Travelers Ins. Co., 37 Misc.3d 19 (App. Term 2d, 11th & 13th Dists. 2012)

Following a thorough review of all the medical documentation submitted in this matter which includes all physician evaluations, follow-up reports, and the IME report, I find these physicians are in direct contradiction to one another. I am, of course, mindful that each of these experts has a distinct interest and/or possible bias for his or her conclusions. That being said, the Applicant contends that the services rendered were medically necessary.

The Respondent contends otherwise. The Arbitrator is thus placed in the position of determining which of these opinions, (both of which on the surface appear credible and cogent), should be accorded the most weight.

Here, there is extensive diagnostic testing of this EIP which demonstrate, among other things, disc herniation at L3/L4, L4/5 with impingement of the ventral thecal sac on both, along with significant cervical findings.

The IME examiner, on the other hand, has positive findings upon testing EIP’s range of motion, both cervical and lumbar and he reviews the positive MRIs, all of which he ignores in deciding that EIP requires no further treatment. The applicant examines EIP the following day and also

finds significant restrictions in ROM.

Applicant Is Awarded Reimbursement Of $9,788.20 Together With

Interest And Attorney’s Fees.