The Insurance Carrier isn't Paying My Bills!?

Most people who get injured at work are surprised when they get their first medical bill denial in the mail from the insurance carrier. It comes on form C-8.1B and typically gives a reason why the bill is being denied. Clients or potential clients say, “but I got hurt at work, how can my treatment be denied, my doctor says I need this so I can get better and get back to work!”

In a NY Workers’ Compensation claim the injured worker goes to the doctor and then the doctor or other medical provider bills the insurance carrier. The insurance carrier then pays the bill or denies paying the bill for any number of reasons.
The most common reasons that the bill is being denied are that the case is being controverted, the treatment provided was for a non-established injury site, the treatment fell outside of the medical treatment guidelines or was otherwise not medically necessary, or the provider filed the bill late.

Once the bill is denied, there are a number of ways that it can be dealt with. If the entire case is being challenged, or controverted, by the insurance carrier then the disputed bills will be taken care of once the judge makes a ruling on whether there is in fact a case. If the injured worker wins and the case gets established, the insurance carrier is then directed to pay any outstanding bills that are causally related to the case. If the insurance carrier wins and the case is disallowed then the injured worker is responsible for the outstanding bills.

If a case is already established and the insurance carrier disputes a bill then the NYS Workers’ Compensation Board will usually send out what is called a Proposed Decision that finds the bills in favor of the medical provider or the insurance carrier depending on the facts and circumstances surrounding the disputed bill. The Proposed Decision is just that, a proposal by the Board on resolving the outstanding issue. These types of decisions usually become final around 45 days after they are issued. This gives both the injured worker and the insurance carrier time to review the decision. If either party disagrees with the findings in the Proposed Decision, then that party may send in an objection to the decision and the Board will either send an amended decision, or bring the case on for a hearing to address the issue.

Here at MCV Law, we carefully review the disputed bills and strive to keep our clients up to date on the status of unpaid bills. Most of the time our clients want to simply understand whether they will become responsible for payment of the bill. We work to help our clients understand these complex issues and help their doctors get paid so their treatment goes uninterrupted.

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