No-Fault Collections Peer Review Denials

New York No Fault Collection Lawyers

There are precise legal requirements that insurance companies and the doctors they hire must follow in order for the peer review denial to be valid, and quite frequently, insurance companies deny claims based on peer reviews that are insufficient or inaccurate.During a peer review, a physician reviews and analyzes the medical records submitted by a patient’s treating physician to the insurance carrier. This review is conducted to determinewhether services rendered by the treating physician to patient were medically necessary. If the peer review concludes that a certain medical serviceswere not medically necessary, the insurance company can deny payment of such services. Peer reviews are supposed to be impartial. Nevertheless, because peer reviewers are paid by insurance companies to determine whether a claim should be denied, they are hardly ever that.

In order for a peer review denial to be successful, beside containing factual, medical rationale as to why the services in question were medically unnecessary, but it must also include that the disputed services were not consistent with generally accepted professional practice. This means that even if a medical expert testifies compellingly that he or she believes the treatment in question was medically unnecessary, if he or she does not show that the treatment was not in line with generally accepted practices, then the testimony will be considered the medical expert’s mere opinion. The resulting testimony can only then be a differing professional judgment, which does not prove the services in question were medically unnecessary.

Unlike an independent medical examination (“IME”), a peer review does not entail a medical examination of the patient. The patient does not have to visit the peer reviewer’s office and does not have to submit to any examinations. Insurance company selects a physician of its choice, and pays him or her to review the treatment records of a certain patient. After reviewing these documents, the peer reviewer creates a “Peer Review Report,” and submits it to the insurance company. Usually, the report will contain the peer reviewer’s medical opinions as to whether the services the treating physician rendered were medically necessary to treat the patient’s injuries. The Law and Peer Reviews.

According to Regulation 68, insurance companies are entitled to conduct a peer review as additional verification of a no-fault claim. If the peer review report concludes that the services rendered were not medically necessary (which it will likely do), the insurance company then has a basis to deny the claim based on lack of medical necessity. However, this does not mean that the medical provider should cease treatment of the patient. If the reason for a no-fault claim denial is a negative peer review report, the insurance company must release a copy of that report to the patient, his or her attorney, and/or his or her treating physician upon request of any of these parties.

Claims denied based on peer reviews can be litigated or arbitrated. To establish a viable denial on the grounds of medical necessity, an insurance company must show that the peer review report “set[s] forth a sufficiently detailed factual basis and medical rationale for the claim’s rejection.”97.5% of denials that are based on peer reviews do not hold up in court or arbitration, and insurance companies are required to pay the treating physician’s claims.

Treating Physician’s Right to Rebut Peer Reviews

Once an insurance company’s physician performs a peer review, the question of medical necessity does not immediately end. A patient’s treating physician can challenge the peer review by writing a rebuttal or by having a third-party physician perform his or her own peer review. Peer review rebuttals raise an issue of fact as to whether services rendered were medically necessary, and thus increase the treating physician’s likelihood of success in litigating the denied claims.

When an insurance company issues a denial based on a peer review, we oppose the denial and use our no-fault expertise to collect on those claims. We have successfully collected on thousands of claims that were denied based on the results of a peer review.

Medical providers can rest assured that 97.5% of denials based on peer reviews are not upheld in litigation or arbitration. Here at Tangent, we pride ourselves on exceeding that standard.

Additionally A peer review report’s factual basis may be insufficient if it fails to provide specifics of the claim, is conclusory, or otherwise lacks a basis in the facts of the claim. See Devonshire Surgical Facility, Carnegie Hill Orthopedic Servs., P.C. v. American Tr. Ins. Co., 2011 NY Slip Op 50513(U) (App Term 1st Dept. April 5, 2011. Even if a peer review is sufficiently factually based, its medical rationale may be inadequate if it fails to demonstrate that the disputed services were inconsistent with generally accepted medical or professional practice. See, e.g., James M. Ligouri Physician, P.C. v. State Farm Mut. Auto. Ins. Co., 2007 NY Slip Op 50465(U) (N.Y. Dis. Ct. 2007.

Choudhry &Franzoni Law Firm – No Fault Collection Lawyers

At Choudhry &Franzoni, PLLC we have the strengths, both financial and in terms of manpower to fight hard for our clients. We refuse to accept low ball offers from insurance companies. We fight hard for our clients and recover the maximum amount allowed by law. We are not ready and committed to take the insurance carriers on in either arbitration hearing or in civil court trails. A Free Consultation With No Fault Collections Attorney is Only A Phone Call Away. Please Call Now 212 LAW 8000.