Physician/Healthcare Provider EUO
No-fault Regulations provide the no-fault insurer with the right to demand, as a condition to coverage, an examination under oath (“EUO”) of the applicant for benefits. As assignee of a claim, a healthcare provider is subject to the same obligation of responding to a request for an EUO. However, while a demand for an EUO of the assignor (patient) is essentially guaranteed, the EUO of a provider is NOT an automatic right of the insurance company. insurance carriers are required to provide some good faith basis for the EUO. The insurer’s right to demand an EUO does not give it unfettered right to disrupt medical professionals. Rather, the insurer must provide good faith reasons, based on objective standards, that serve as justification for the demand for an EUO. There is developing case law regarding what information insurance companies need to provide prior to a request for an EUO. As such, healthcare providers should consult an attorney upon demand for an EUO. Our no-fault attorneys have the knowledge and experience important to protect your rights.
The EUO is a verification tool used typically on claims being investigated by the insurance company. No-fault insurers use this procedure if they suspect a claim may be fraudulent or to dispute coverage. The insurance company will typically ask questions about your experience and treatment of the patient but may also want to inquire into your billing practices, your finances, your employees, and how your patients are referred to you. Based on the answers given, they can also ask you to produce documents, including tax returns, bank statements, leases, loan agreements and expense documentation. While the questions posed at the EUO may seem inconsequential, there are serious ramifications to the information provided, least of which might be denial of the claim.
EUOs are considered a policy condition to coverage. Failure to submit for an EUO is a “material breach” of an insurance policy that precludes coverage for future claims for that patient, arising out of the same accident. Pending claims may also be denied. If the pending claim is for treatment provided prior to the “EUO no-show”, a denial by the insurer may be found to be ineffective by an arbitrator or judge. A successful denial of claims due to a “no-show” defense does not create a right of recovery for the insurer for any benefits previously paid.
Before submitting to any EUO, it is important to consult with an attorney who knows what laws are in place to protect you. Our experienced no-fault attorneys can help you avoid unjustified requests for EUOs that take you away from time that would otherwise be spent providing health care to patients.
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