Compliance

The Rules and Regulations of no-fault can wreak havoc on a health care provider’s practice. Compliance with these many rules and regulations is a burdensome task. Our attorneys keep track of it all so our providers can focus on their practice. Here are a few of the basic rules and defenses to be aware of under the no-fault regulations.

The 45-Day Rule: A medical provider must submit medical billing to the insurance carrier within 45 calendar days from the date of service. The medical provider must include the date of service when counting the 45 Days. Generally, proof that a medical bill was properly mailed gives rise to a rebuttable presumption that the item was received by the carrier. The presumption may be created by either proof of actual mailing, or proof of a standard office practice or procedure designed to ensure that items are properly addressed and mailed. If a medical provider cannot verify the billing was sent within 45 calendar days from the date of service, the No-Fault regulations do allow for a provider to present a reasonable justification for the delay. The No-Fault regulations require insurers to process late claims when the excuse that is offered by the medical provider is difficulty in ascertaining the identity of the insurance carrier, or if the medical provider inadvertently submitted the bills to the wrong carrier.

The 120-Day Defense: Upon making a request for additional verification, the insurance company’s time to pay or deny a claim is tolled until such time as all relevant information is received. A medical provider has 120 days to respond to verification requests asking for documents. If not submitted within 120 days of the initial request, then the insurer may deny the claim for failure to supply the verification, regardless of whether the denial is timely. Failure to respond to any verification request – even those that may not be applicable – may result in a denial. If the document does not exist or is not in the custody or control of the provider, a response MUST still be sent.

The Independent Contractor Defense: No-fault regulations prohibit a billing provider from recovery of no-fault benefits where the medical services were performed by an independent contractor. No-fault medical billing is limited to W-2 employees of the health care provider. Where the owner of a PC is licensed to performed health services and such services are performed by the owner or an employee under the supervision of the owner, the services may be billed for under no-fault. Services performed by a provider who is an independent contractor with the PC and is not an employee are not billable under no-fault by the PC. The independent contractor defense is non-waivable and not subject to the preclusion rule.