NYS No-Fault Insurance, Intoxication & Verification Requests
Why healthcare providers need to consider the significance and weight of replying to verification requests.
The Significance and Weight of Replying to Verification RequestsIntoxicated drivers are a danger to themselves and everyone else on the road. It is a matter of when, not if, they will be involved in a motor vehicle accident. When intoxicated drivers are injured as a result of accidents, it can present a complicated situation for no-fault providers who treat them. More specifically, the driver's intoxication may void their insurance policy coverage, placing the provider in the precarious position of having to choose to treat a patient in need, despite the fact they may never be reimbursed from the no-fault carrier for their services.
There is, however, an exception to the No-fault Regulations for the reimbursement of "necessary emergency health services rendered in a hospital" to an intoxicated driver. This is a narrow exception and may not apply to many providers.
If a carrier intends to deny a claim based on intoxication, they must do so in writing within 30 days of receiving a claim. If the insurance carrier does not deny the claim outright, they often will request verification from the provider. Verification requests that concern cases involving intoxication often request information that a provider, aside from the hospital treating the patient immediately after the accident, will have absolutely no ability to provide. (Documents such as: hospital admission/treatment records, BAC test results or criminal proceeding disposition documentation, etc.)
What should a provider do when they received a delay letter requesting additional verification?Respond. It is imperative that the provider respond to a verification request (all verification requests, not just those concerning intoxication). Even if the carrier's verification requests are defective and they make outrageous and impossible demands, it is necessary for a provider to respond saying why they cannot comply with the request. It takes the ball and puts it back in the carrier's court, and then it is incumbent upon the carrier to acknowledge and address the provider's contentions.
Our office recently won such a claim at arbitration...The provider we represented had thousands of dollars in treatment bills delayed on the grounds that he failed to provide the "outstanding verification" requested concerning the alleged intoxication of his patient at the time of the accident. The carrier requested the hospital records, the toxicology report, the hospital bills, and the criminal charge disposition documents against the eligible injured party as they related to the accident. Procedurally, the carrier complied with the rules for requesting verification, which initially provided a strong defense at arbitration. But our office, on behalf of the client, sent a substantive and detailed response letter as to why the carrier was not entitled to the information sought. In short, the provider did not have physical custody, control or access to the documents requested. Further, the insurance company never responded to the provider's reply.
As stated by the arbitrator: "Respondent is not free to merely sit on its laurels and ignore applicant's response to its verification requests, as 'there is no provision of the No-Fault Regulations which allows the claimant or insurance company to ignore a verification request or response... Any questions concerning communication should be addressed by further communication, not inaction.' "
Subsequently, the arbitrator awarded the client the full award of $7,889.07.
This shows the significance and weight of replying to verification requests.