Many carriers automatically reimburse private health insurance providers in full for medical treatment and prescriptions that were initially billed to the private health insurance provider rather than a workers’ compensation carrier. In many cases, full reimbursement is not appropriate. There are many valid defenses to paying some or all of these reimbursement requests.
The process for disputing these types of reimbursement requests are set forth in 12 NYCRR §325-5 through 12 NYCRR §325-6.17.
One particularly strong defense all carriers should be aware of: 12 NYCRR §325-6.2(b) states that “any claim for reimbursement must be filed within three years of the date of payment by the health insurer for services rendered by a provider or by October 15, 1992, whichever is later, as provided in §13(d) of the Workers’ Compensation Law.”
This provision acts as a statute of limitations so that you cannot be held responsible for any treatment or prescriptions paid for by the private health insurer unless the bill is submitted to you for reimbursement within three years of the date the service was rendered and paid by the private health provider. For example, if a private health provider pays a $5,000.00 bill for treatment that should have been properly billed to the WC carrier on 01/01/15 but neglects to request reimbursement prior to 01/01/18, you cannot be compelled to reimburse them.
There are other defenses set forth in 12 NYCRR §325.5 through 12 NYCRR §325-6.17. We have recently been successful in getting private health insurance providers claims for reimbursement significantly reduced or eliminated using these regulations for many clients. You should always scrutinize these reimbursement requests carefully to determine whether you have any valid legal defenses to payment prior to reimbursing the private health provider.
We are available to help assist you with the defense of these types of claims. Please contact either Patrick Guy at firstname.lastname@example.org or John Snyder at email@example.com if you need any assistance or would like to discuss this topic in more detail.
This information is provided for general guidance only. This information should not be used as a substitute for consultation with legal counsel. Each case presents unique facts requiring individual analysis.