Here is a summary of legislative and regulatory developments and challenges in the fourth quarter of 2021 and their practical implications:
New York: Amendments to the Workers’ Compensation Board Medical Billing Disputes regulation became effective on November 1. These amendments require all objections to medical bills be filed with the Board simultaneously rather than sequentially. As amended, 12 NYCRR 325-1.25 now provides that the Board will deny any objections to payment of a health care provider’s bills that are not raised simultaneously in Form C-8.1, including objections based on legal, valuation or Medical Treatment Guideline grounds. The regulation is further amended to require payers, if the objection relates to the provider’s failure to obtain prior authorization, to provide with the filing evidence that the prior authorization request was actually denied.
Implications: The New York State WCB, in adopting these revisions, cited the need to expedite the resolution of medical payment disputes in the interest of administrative efficiency. The new requirements, however, appear to place the burden of improved timeliness primarily on insurers, employers and TPAs. The revisions may present challenges for payers’ claim staff in compiling and presenting all potential objections to medical bill payment within New York’s 45-day prompt payment timeline.