CAN I BILL PERSONAL INSURANCE IF IME DENIES CLAIMS?

Today’s question:  If services are denied from and IME or URO, can i then bill these charges to personal insurance?

Generally speaking — NO!  If services are denied by the IME (Independent Medical Examinor) or URO (Utilization Review Organization) (or PRO – Peer Review Organization)  as being not medically necessary, then we recommend that you not bill those charges to personal insurance.  Primarily, because an “expert” reviewing body has determined that the services do not meet the definition of medical necessity.  And this finding gives the presonal insurance a prime reason to request a repayment of any money you receive.  Yes, you may get payment.  But if the personal insurance conducts a post payment review, that money will be requested to be refunded.  Moreover, those services will be built into the calculations for the total payment request, which will skew the total refund requested in the favor of the insurance company.

If the IME or URO deny charges as not being related to the accident (work comp or auto) then there is a possiblity that you may be able to bill personal insurance for the charges. 

Generally speaking auto and work comp carries have a very narrow view of the injuries related to an accident.  You must be very clear in your documentation to relate the treatment to both the mechanism of injury and injuries reported to the patient.  If you are providing services that are not related to the accident, those services need to be billed to personal insurance, and not as part of the accident. 

Keep in mind, that if a URO or IME review is requested, this often occurs after a prolonged care period.  If you charges are denied as not related to the accident, and you bill to personal insurance they may deny the medical necessity of care based upon the length of care and the acute condition of the patient. 

We suggest extreme care in billing these charges to personal insurance.   Be sure that your documentation clearly delineates the care related to the accident and be sure that your documentation clearly shows medical necessity.