Healthcare providers treating patients under No-Fault insurance may be requested to submit to an examination under oath (EUO) by a No-Fault Insurance Carrier. See, 11 NYCRR 65–1.1. Just like other verification requests, there has been a significant increase in the abuse of provider EUO requests utilized by Insurance Carriers as tool to deny, delay and not pay viable claims submitted by legitimate healthcare practitioners. This can cause a significant financial strain on a healthcare provider. A provider EUO request can essentially freeze any and all pending payments from the requesting Insurance Carrier until the EUO issues are resolved. As such, it is extremely important to forward any provider EUO request to your attorney. Your attorney must be competent, skilled, knowledgeable and experienced in this area of law.
This law firm has extensive experience representing healthcare providers in dealing and addressing provider EUO requests. If you have received a letter requesting you to appear for an EUO, please contact this office via email at firstname.lastname@example.org or call (631) 656-8180. We will give you a free consultation and we will explain your legal rights and explore your options. We will zealously and competently represent and defend you with any EUO request. If necessary, we will litigate or arbitrate any unresolved issues and any unpaid claims.
Things You Need To Know About Provider EUO’s:
First and foremost, failure to appear and comply with an EUO request is considered a violation of a condition precedent and a material breach of the patient’s No-Fault policy, which precludes you to recover on unpaid claims. Therefore, immediate action is required and legal representation is highly recommended.
The EUO stage is conducted during the verification of the proof of claim stage. According to the law, the Insurance Carrier shall not be adversarial. In fact, the Insurance Carrier is required to assist you. The pertinent provisions of 11 NYCRR 65-3.2, states in pertinent part.
Claim practice principles to be followed by all insurers.
1. Have as your basic goal the prompt and fair payment to all automobile accident victims.
2. Assist the applicant in the processing of a claim. Do not treat the applicant as an adversary.
3. Do not demand verification of facts unless there are good reasons to do so. When verification of facts is necessary, it should be done as expeditiously as possible… (Emphasis Added).
Why Do Insurance Carriers Request EUO’s?
There are a number of reasons why Insurance Carriers want to conduct an EUO. First and foremost, they know that they can use this device to delay, deny and eventually not pay viable claims. However, an Insurance Carrier may claim that they discovered some issue during their verification of a proof of claims submitted by other providers or during an EUO of the patient. For example, a patient may not recall the services provided to them, they bring up some issue that requires further verification from the provider or the patient may have even claimed that some of services billed for were not rendered. Sometimes they notice a pattern of billing and they want to inquire into whether there is excessive billing. They might have issues pertaining to the whether you have employees working for you or independent contractors.
An Insurance Carrier may use an EUO request to look into your so-called corporate structure. This is an area you definitely need to explore before you sit down for your EUO. There is sufficient evidence that Insurance Carriers use the EUO request in hopes that a provider will not show up for an EUO and thus they will not have to pay the provider for all bills submitted. In fact, there have been a number of carriers that will drop their EUO request once you inform them and they know you are serious of attending.
Where are the EUO’s held?
Most Insurance Carriers and their attorneys will schedule the EUO at a location convenient to them- their attorney’s law office. However, under No-Fault law, you are entitled to have the EUO at a convenient location, time and date, but you must object to the location, preserve and raise this issue in your response, otherwise you will waive this right.
What Are The Insurance Carriers Looking for at an EUO?
An insurance carrier will typically ask you questions surrounding your knowledge and treatment of the patient(s). This includes questions concerning the type of treatment your facility rendered to them and the medical necessity of the services provided. An Insurance Carrier may also wish to inquire into your billing practices, the CPT codes you utilize and bill for and frequency of billing. They will most likely ask questions pertaining to the names of your employees, whether they are employees or independent contractors and how you get your referrals.
Most significant, Insurance Carriers often use EUO requests to delve into your so-called corporate structure. They will attempt to explore whether your corporation is in compliance with N.Y. Business Corporation Law §§ 1507, 1508, and N.Y. Education Law § 6507(4)(c). Unfortunately, the Insurance Department, Department of Financial Services (regulatory body overseeing insurance) and the New York State Court of Appeals have held that the Insurance Carriers are afforded this right. See, State Farm Mut. Auto. Ins. Co. v. Robert Mallela, 4 N.Y.3d 313 (2005). 11 NYCRR § 65-3.2 (c) states an insurance carrier can only delay payment of a claim to pursue investigations solely for good cause. In the licensing context, carriers will be unable to show good cause unless they can demonstrate behavior tantamount to fraud. The insurance carrier bears the burden of proving that the provider’s conduct rises to the level of “behavior that is tantamount to fraud”.
There are limits and provisions that guide and protect abuse and they are finally being enforced by Courts and Arbitrators. An Insurance carrier is not entitled to engage in a fishing expedition. Nevertheless, Insurance Carriers unquestionably use EUO’s to their advantage in the hopes of not delaying, denying and not paying claims, which is in direct contradiction the purpose and intent of No-Fault law. Therefore, you need to be represented by a skilled, competent and experience law firm to protect your rights.
Finally, some insurance carriers will demand the production of documents pertaining to financial statements, ledgers, tax returns or bank statements. This is highly sensitive and there are limitations on what information you need to provide and turnover to the Insurance Carrier. Tax returns are generally not discoverable in the absence of a strong showing that the information is indispensable to the claim and cannot be obtained from other sources. Compelled disclosure of income tax returns is disfavored because of their private and confidential nature. Thus, the party seeking such disclosure must make a strong showing of necessity and demonstrate that the information contained in the returns is not available from any other source.
Are You Entitled To Know What Information The Carrier Is Looking For before you sit for an EUO?
The short answer is yes. The better answer is- you should be. The developing case law seems to support disclosure of said information. Although most insurance carriers and their attorneys generally and routinely refuse to give you information pertaining to the basis and reason for said EUO request prior to you appearing, there is some developing case law requiring said production. As such, you need your attorney that is knowledgeable about the law and a law firm that has experience arguing these issues before a Court or Arbitrator.
Again, if you have received a letter, notification and or scheduling request to appear at an EUO, please feel free to contact this office at any time via email email@example.com or (631) 656-8180. We will zealously and competently represent and defend you at the EUO. We will give you a free consultation and we will explain to you your legal rights and options available to you as a healthcare provider.
The Law Office of
Gregory A. Goodman, P.C.
380 North Broadway
Jericho, New York 11753