07/24/2024 - Medical provider disputes resolved faster than ever

The NYS Workers' Compensation Board has made huge improvements in resolving billing disputes between health care providers and payers, which has led to significantly reduced turnaround times. This means health care providers are now getting the payments they are due faster than ever!

Two years ago, the Board's Medical Director's Office (MDO) embarked on a project to significantly improve the effectiveness and efficiency of the medical billing dispute process. At the time, the Board's processing time for Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) could take as long as two years. We correctly heard from the provider community that this timeframe was simply too long, and that it was a significant source of dissatisfaction with the workers' compensation system.

In response to these concerns, the MDO did an in-depth assessment of the billing dispute resolution process and implemented a complete overhaul. The many system improvements included converting to a paperless process; improving workflow tracking and file stewardship; and communicating streamlined information requirements to both providers and payers.

Thanks to this hard work by the MDO, the Board has made tremendous progress in reducing the backlog and improving overall turnaround times.

• Administrative HP-1 Awards (simple disputes over fee amounts or nonpayment): In the spring of 2023, there were over 36,000 outstanding HP-1s for administrative award review, with an 18- to 24-month turnaround time. That number today is down to just 4,000 - the oldest of which is from May 2024. Current turnaround from receipt of HP-1 to when payment is awarded is less than two months (and getting shorter).
• Arbitration HP-1 Awards (more complicated disputes requiring an arbitration process): In January 2023, the backlog of HP-1s to be handled through the arbitration process was approximately 8,400. Today, there are just about 1,540, with the oldest HP-1 received for typical arbitrations from June 2024. While there will always be at least a one- to two-month lag for these HP-1s due to regulatory timeframes for payers to respond/object, the current turnaround from receipt to resolution is two to three months (excluding dental arbitrations and a very small number of highly specialized arbitrations).

Decreasing the resolution time for disputed medical bills is just one of several actions the Board has taken in recent years to make the NYS workers' compensation system better for providers. The ultimate goal is to increase provider participation, so New York's injured workers have better access to high-quality medical care.

To help providers and payers navigate the billing disputes process, the Board recently launched a medical billing disputes webpage that offers a one-stop shop for all related information, including required action and documentation for the most common scenarios.