Medical Necessity Claim Lawyer in NY

Woman in a medical mask talking with the doctor

You’ve cared for a patient involved in a No-Fault automobile accident and submitted a claim for reimbursement but you were shocked to find that the insurance company promptly denied reimbursement because the treatment was allegedly unnecessary. Even if the insurer does not deny your medical treatment, they may deny reimbursement for medical supplies, tests, imaging studies, or other services.

To support their medical necessity-based denial, the insurance companies will partner with doctors to provide expert opinions about the injured person’s care. This “peer review doctor” is, in theory, an independent third party providing unbiased information based on their professional experience. The unfortunate reality is that the insurance company pays these doctors a fee, and they typically understand that they will continue to be paid these fees if they opine in favor of the insurance company. 

We know of at least one insurance carrier that frequently uses a peer review doctor who violated mandatory standards during his testimony in legal proceedings. This insurance carrier continues to use this doctor for peer review opinions. 

What to Do After a Medical Necessity Denial of Your No-Fault Claim

The best path forward is to partner with a New York No-Fault Attorney who is familiar with the No-Fault insurance claims and appeals process, like one from the team at The Sigalov Firm. We have a number of successful methods for appealing and discrediting expert opinions about why you administered so-called “medically unnecessary” treatment. Our strength is the ability to discredit the peer reviewer’s medical report. We do so in the following ways:

Identify Logical Fallacies In the Report

A good place to start is by identifying any logical fallacies in the report. A logical fallacy is an error in reasoning that can lead to an invalid conclusion. If we can find a way to invalidate the reasoning of the peer review doctor, then we can also invalidate their conclusions.

Highlight the Peer Reviewers’ Failure to Articulate the Standard of Care

One common way that we are able to discredit the peer review opinion is by showing that the doctor failed to articulate the medical standard they used to come to their conclusion. For a doctor’s opinion to be credible, he must explain what the proper standard care is and how it wasn’t followed in this case. Failure to affirmatively state the proper standard of care is the type of deficiency we use with good outcomes for our clients. 

Bring in Your Own Expert Witness

In some cases, we will also bring in our own expert witness to provide testimony about the care that was administered. This allows us to directly refute the peer review doctor’s opinions and provide context for why the treatment was necessary.

Cite a Failure to Identify Positive Findings in the Medical Records

In other cases, we may find that the peer-review doctor failed to identify positive findings in the medical records. This is often due to a cherry-picking of information, where the doctor only includes information that supports their opinion while ignoring anything that may contradict it. When a peer review omits any of the positive findings that led to your decision to provide treatment, we may be able to successfully impeach the report in the eyes of the fact finder (i.e. arbitrator). 

Cite a Failure to Submit Medical Publications Referenced in Peer Review

We have also seen cases where the peer review doctor will reference medical publications in their report but fail to submit those publications as part of the review. This may be an indication that the doctor is cherry-picking information and is not providing a comprehensive overview of the situation. In many of these cases, the information in the medical publication may not even support the peer reviewer but may indeed stand for an entirely contradictory position.

Discredit the Peer Reviewer’s Credentials or Credibility

In some cases, we may be able to discredit the peer review by calling into question the credentials or credibility of the doctor. This can be done by bringing up any past disciplinary actions or by showing that the doctor does not have the necessary experience to render an opinion on the matter at hand.

The above are just a few examples of the strategies that we use to appeal a medical necessity denial. 

Contact The Sigalov Firm Today To Schedule a Free Consultation

The medical necessity appeals process is complex, and it is important to have an attorney on your side who knows how to navigate it. If you have received a denial for payment following medically necessary treatment, contact The Sigalov Firm today to discuss your options. There are plenty of examples of claims denied by insurance companies on perfectly reasonable grounds, but you cannot assume all No-Fault denials are fair and valid. Insurance companies deny countless claims yearly after No-Fault care is provided, and the cost is passed back to you as the healthcare provider and your patients.

The Sigalov Firm knows how to navigate the often-confusing world of No-Fault insurance. We are here to help you get the reimbursement you deserve. Take the first step and contact us today to schedule a free consultation.