Prepare! Prepare! Prepare!

One word which will make all the difference in the success of a no-fault claim is “preparation.” Undoubtedly, there are too many instances where the insurance companies undeservedly deny a no-fault claim. However, if a health care provider does not have the necessary documents to dispute the denial, collecting on that claim is far less likely.

The evidence filed with a request for arbitration is the essential foundation for success. There are those documents that are necessary and, without which, the request will never be heard. If you do not have these initial documents, the American Arbitration Association (AAA) will reject the request outright. Then there are those documents which may not technically be required, but, if included, increase the chances greatly of collecting on the unpaid no-fault claim.

In order to file a no-fault collection proceeding, a provider MUST include the following documents in any request:

  • Assignment of Benefits signed by the patient and health care provider (AOB)
  • All outstanding bills (NF-3) (HCFA 1500)
  • Medical report(s). Typical mistakes occur here with the medical report right at the outset! Explained further below.

Above is the minimum that will be looked for to process a claim for arbitration. But the minimum will often not be enough to get you a favorable award. While the request may pass through so long as a medical report is included – any medical report – it is the novice mistake to submit one random medical report and expect that to be sufficient. Contemporaneous medical documentation is the key to success!

The medical reports should relate specifically to the claims at issue and more importantly, the denials! If the claim involves a medical procedure such as surgery, all evaluations leading up to the surgery should be provided – from both the surgeon and any referring doctor. A letter of medical necessity should also be provided from the surgeon. If a peer doctor of the insurance company denied the surgery, a rebuttal letter from the surgeon should be submitted. If cervical or lumbar MRIs were denied on a peer, a rebuttal from the doctor or chiropractor who ordered the MRI should be submitted, as well as the initial evaluation and any re-evaluations. Physical therapy, chiropractic treatment and acupuncture services are too frequently denied on the results of an Independent Medical Exam (IME). It is imperative to submit re-valuation reports to contradict the IME findings. The key to overcoming the denial is having the proper medical reports. So, prepare, prepare, prepare and include:

  • Narrative reports: evaluation report and re-evaluations reports
  • Letter(s) of Medical Necessity
  • All medical reports from outside medical referrals
  • Results of diagnostic testing
  • Progress notes
  • Any Independent Medical Examinations (IMEs) or Peer Reviews

Your submission will be carefully reviewed by our staff and attorneys to make sure we have the documents needed to win your case and collect money due and owing you. Please contact Anthony Licatesi directly at 516-478-0210 or email [email protected]