Article 28 Facilities No-Fault Collection Provider in New York City

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Article 28 is a public health law responsible for regulating and recognizing accreditation for public health care facilities to ensure that these facilities are properly licensed and operated. Under Article 28, certain facilities are licensed to perform specific types of procedures that may not be lawfully performed under other circumstances. Hospitals, surgical centers, and nursing homes can all fall under the Article 28 umbrella.

Article 28 is a benchmark of high standards in the state of New York’s health care services. It ensures that public healthcare facilities are both legitimate and properly operated. As such, accreditation under the Article 28 process signifies a facility’s adherence to the strictest standards. Coding and billing under Article 28 may be complicated, often more so than for a medical facility that has not earned the designation.

The team at The Sigalov Firm PLLC has years of experience supporting healthcare providers through the collections process, providing the knowledge and experience necessary to handle these claims on behalf of the healthcare facility. 

Understanding the No-Fault Insurance Law

The services provided by healthcare providers accredited under Article 28 may cost more, due in part to the expense of rigorous adherence to high standards of care. The higher cost of care in an Article 28 facility also leads to higher scrutiny from insurance carriers that are focused on controlling their costs. 

If your patient was injured in a car accident, the automobile insurance carrier should pay your healthcare facility bill. New York’s No-Fault Insurance Law was originally designed to ensure that car accident victims have access to quality medical care, regardless of who was at fault for the accident. To receive this compensation for your No-Fault bills, you will need to file a No-Fault claim with the patient’s insurance company. Once you file a claim, your facility is entitled to reimbursement for all “reasonable and necessary” treatment. 

Common Reimbursement Denials Under New York’s No-Fault Laws

In some cases, insurance companies are reluctant to pay out these bills. There are a number of reasons why they may deny your No-Fault claim, the most common are as follows below. 

Lack of Medical Necessity

Most commonly, the insurance company simply claims that the treatment your facility provided was not “reasonable and necessary” and, as such, not covered under the No-Fault law. In order to make this denial, insurers will work with an independent doctor on a “peer review” based medical denial, saying the care you provided was not necessary.

This doctor does not speak with or see the patient in person, and only uses their medical records to make a determination. In some cases, the doctor contracted by the insurance company may overlook important details when determining whether or not your facility provided appropriate healthcare to a No-Fault patient. We have years of success refuting denials based on expert opinion with a number of remedies.

Independent Medical Exam Findings

As with a peer-review doctor finding that your care was not medically necessary, an Independent Medical Exam (IME) is another way that insurance companies “verify” a patient’s condition before determining whether or not it is appropriate to pay for claims you may submit in the future. 

The examining doctor may determine that the patient’s recovery is complete or may downplay and outright dismiss specific injuries. Based on this opinion, insurance companies will deny either part or all of a medical facility’s bills, and it is up to you to provide a rebuttal.

Missing Documentation

To receive reimbursement, you will need to provide the insurance company with detailed documentation of the care that was provided. If this documentation is incomplete, the insurer will likely send you a claim verification request. Verification requests cannot be ignored, even if they aren’t reasonable and even if the requested materials have already been submitted; at the very least you must reply to say that the materials have already been provided. Ignoring verification requests, even if unreasonable, will likely lead to a denial that will be sustained during a No-Fault arbitration or litigation and you won’t be able to recover on your claim. 

We recommend that your facility’s billing department focuses on ensuring that every necessary and supporting documentation is included with each claim. 

Contact The Sigalov Firm Today

If you have been denied reimbursement for a No-Fault claim or are at a standstill attempting to get insurance companies to pay out on the claims you’ve submitted, our team can help.

In some cases, insurance companies are reluctant to pay No-Fault claims. While frustrating, you likely have a good path toward substantial recovery. The New York No-Fault Attorneys at The Sigalov Firm PLLC has the experience and knowledge necessary to guide you in the right direction. We will help you navigate this process and fight for the compensation you and your facility deserve. 

Contact us today for a free consultation, and let the No-Fault collections attorneys at our law firm help you recover the compensation that your Article 28 facility is rightfully owed after providing care.