May a healthcare provider that has accepted a No-Fault Assignment of Benefits from a No-Fault claimant pursue the patient directly for payment if the No-Fault carrier denies payment for services based upon a determination that the services were not medically necessary where the healthcare provider also obtained a lien form from the No-Fault claimant against claimant's 3rd party personal injury claim/action?
No. Even if the healthcare provider obtained a lien form from the No-Fault claimant, it would still be prohibited from pursuing reimbursement directly from the claimant by the Assignment of Benefits language contained in the claim forms required by Reg. 68-C.
Can a healthcare provider resort to a patient's private health insurance carrier for payment where a valid Assignment of Benefits was signed, treatment was denied for lack of medical necessity, and said denial was upheld at arbitration or litigation?
No. The NYS Department of Financial Services has advised that the same rationale from above applies, and that pursuing health benefits from the patient's health insurance carrier would be prohibited by the prescribed Assignment of Benefits language contained in the forms required by Reg. 68-C.
In sum, the only instance where a healthcare provider MAY resort to the patient or the patient's private health insurance is when No-Fault benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor (such as a failure to show at the IME or EUO).
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