Insurers Back N.Y. DOI’s Proposed No-Fault Fixes

May 10, 2004

The New York State Insurance Department’s proposed amendments to Regulation 83 would reportedly move the state’s no-fault auto reparations system toward more measured and reasonable cost control without sacrificing treatment for injured persons.

“PCI specifically praises the proposal’s establishment of consistent and reasonable values for the cost of durable medical equipment,” said Donald Cleasby, assistant vice president, regional manager and counsel for the Property Casualty Insurers Association of America (PCI). “This has been an area of widespread billing abuse and this new schedule will help address that problem.”

However, in a letter to the New York State Insurance Department, Cleasby pointed out several areas of concern, including:

* The statement that workers’ compensation pre-authorization approval rules do not apply to auto insurance no-fault. “Pre-authorization for workers’ compensation have proven most useful when dealing with soft tissue injuries, which are highly susceptible to excessive treatment and over utilization,” Cleasby noted.

* Failure to define the term “treating provider.” PCI recommends the wording say “a licensed healthcare professional acting within the scope of his or her licensure or a properly licensed and formed entity acting within the scope of its license billing for the services provided by the service provider.”

* The use of the phrase “during the same period of time” to determine when more than one health care provider treats a patient for the same condition. “This phrase is too vague and should specifically reference a time period such as ‘the same week’ or ‘the same day,'” Cleasby said.

* Requirements that a treating provider must be in compliance with relevant licensing requirements, which should be changed from criteria “mandated and specified under the New York State Education Law” to “compliance with any licensing, training, qualification and experience requirements mandated and specified under New York State Law, including but not limited to any applicable provisions of the Education Law, Public Health Law and Business Corporation Law.”

“We realize our comment letter raises many unanswered questions,” Cleasby said. “But we wanted to alert the Department to the kinds of questions insurers have raised, since it is these carriers that will be expected to abide by the regulation once amended.”

Was this article valuable?

Here are more articles you may enjoy.