New York no-fault is a simple enough concept. Someone gets injured in an accident and their car insurance will cover up to $50,000 for their medical bills. However, in practice, not so simple. Insurers can challenge claims submitted by medical providers for reimbursement. One of the main challenges insurers raise to avoid reimbursing these claims is an allegation that the medical provider received their patients through “kickback” arrangements.
Last week, the New York State Court of Appeals addressed this issue of whether an insurer can deny paying no-fault benefits to a provider if they claim the provider violated licensing requirements by paying for patient referrals in Government Employees Insurance Company (GEICO) v. Igor Mayzenberg. The answer is no (unless there is evidence the medical practice is operated by unlicensed individuals). To find otherwise would essentially undermine the Board of Regents’ ability to handle professional misconduct allegations. Having ruled that, the Court specifically left open, and did not rule on, the issue of whether a large enough kickback scheme could amount to unlicensed control of a medical practice, which may allow insurers to deny such claims.
The Court further recognized that this decision does not impact an insurer’s right to challenge medically unnecessary services. Overall, this decision will likely change the basis for insurers’ verification requests and RICO filings since “kickback payments” have historically been a focal point of these actions.
Garfunkel Wild’s RICO Defense Group is comprised of a team of litigators with specialized experience in handling RICO cases during all stages of litigation, from requests for verification, including requests for examinations under oath, through trial, appeals, and/or settlement.
Should you have any questions regarding the above, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].
