Peer Review Denials Attorney NY
As a No-Fault medical practitioner in New York State, you may already be aware of the many different reasons that a claim may be denied for the care you have already provided. One such denial is through the use of a medical peer review report. This is an external review process where the insurance provider will have a neutral third-party review all of the patient’s medical records and documents associated with a claim to make sure that the services provided were medically necessary and are therefore entitled to be reimbursed.
Being denied for legitimate services based on peer reviews can be frustrating but working with a peer review denial attorney in New York is one of the easiest ways for you to gain the best possible outcome in your situation. A skilled attorney can review all of the necessary documents, make sure that all of the criteria for a peer review have been met, and provide guidance throughout the entire appeal process.
With the help of the team at The Sigalov Firm PLLC, you will be able to protect your interests and ensure that any denials are overturned in a timely manner. Our attorneys understand the complexities of No-Fault law, and we can provide you with the legal guidance you need to file a successful appeal. Contact us today for more information about our services and how we can help in your peer review denial case.
What Is a No-Fault Medical Care Peer Review?
Under New York’s No-Fault Medical Care Peer Review process, peer reviewers provide an opinion to the insurance company on whether they believe the patient received the appropriate standard of care, and therefore whether or not the healthcare provider is entitled to the compensation they are requesting for such services. These peer reviews must be conducted in accordance with both New York State law and applicable professional standards.
The purpose of the peer review is to determine if there was a deviation from the appropriate standard of care. The peer review process includes a detailed analysis of the medical records including patient history and physical examinations, diagnostic imaging studies, lab results, and any other relevant information.
The problem is that there are many instances where a medical practitioner is denied payment based on a peer review, but the review is based on faulty evidence or incorrect interpretation of the facts. In these cases, the healthcare provider can take their matter to arbitration or court to have the matter decided.
Common Reasons for Peer Review Denials
Some of the most common reasons for peer review denials include the following, but are not limited to:
Medical Necessity
When healthcare providers are found to have provided treatment that was medically unnecessary, they can be denied payment on a no-fault claim. However, as the practitioner, you are in the best position to determine what is and isn’t a medical necessity, and we will work to clarify the medical rationale that you were doing what was best for the patient.
Failure to Adhere to the Standard of Care
This is a very common reason for a peer review denial, as it means that the care provided did not meet acceptable medical standards. Much like denials based on unnecessary treatment, we will work to clarify the type of care you provided and why it was medically necessary based on your initial medical examination as the treating physician.
Inadequate Documentation
It is essential that medical providers document any preexisting conditions, as well as the patient’s response to treatment. These denials are often the result of omitted information from the health plan that we will collect and provide for your appeal.
Coding or Billing Errors
Like inadequate documentation, these errors are often easy to rectify, and can be the basis of a successful appellate process. We will work with you to identify coding or billing errors and help correct them before your appeal is filed.
Contact the Sigalov Firm Today
If your practice has been denied payment based on a No-Fault Medical Care Peer Review, contact our office today to request a free consultation. We can review your case and provide you with examples of prior results and cases where we reached a similar outcome to what we expect with your situation. We understand the complexities of claim denials and will work closely with you to help get your appeal heard. Let us help you get the compensation that you deserve.
Works Cited
https://www.dfs.ny.gov/complaints/file_no_fault_arbitration
https://nysinsurance.adr.org/programs/no-fault
https://www.dfs.ny.gov/insurance/ogco2004/rg041001.htm
https://www.health.ny.gov/regulations/public_health_law/