Many facilities that regularly deal with NY No-Fault Insurance are experiencing a serious increase in a certain type of denial.
Denials or reductions due to the patient treating elsewhere on the same day.
Physical Therapists, Massage Therapists, Chiropractors, the list goes on and on.
Why is it happening now and what can be done about it?
There are a few answers to that question.
The first is that the new Workers Compensation Fee schedule began to apply to No-Fault insurance for services rendered on October 1 of this year.
A few new rules have become clearer and more explicit for those providers permitted to bill for Physical Medicine services.
Physical Medicine Ground Rule 1A limits the total amount of Physical Medicine Relative Value Units that a patient may receive in one day to twelve, fifteen or eighteen, depending on the circumstances.
That limit is applied to the patient, for the accident, per day.
Notice that there is no language about multiple providers treating on the same day?
That is because the rule clearly expresses the Boards desire to limit the RVUs that a patient may receive across all specialties permitted to bill for Physical Medicine modalities.
To be clear the RVU limit is written to apply to anyone and everyone billing for physical medicine modalities to the same patient for the same accident on the same day.
This is not the first time that No-Fault practitioners and billers have seen a similar reduction applied.
Some people may recall issues with “Concurrent Care” denials.
Those were often fought over in arbitration with a range of outcomes.
The new ground rule is meant to codify a similar logic and there does not seem to be much that can be done.
Questions about the ground rule explicitly referencing the Workers Compensation Treatment Guidelines are well placed here.
There are going to be hard fought battles over whether or not this rule has just brought those Treatment Guidelines into No-Fault.