Buckeye Actuarial Continuing Education April 26, 2011. No Fault New York – Is it as good as originally advertised? Al Neis FCAS, MAAA Progressive Corporation. New York - No Fault. Insurance Research Council
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Buckeye Actuarial Continuing EducationApril 26, 2011
No Fault New York – Is it as good as originally advertised?
Al Neis FCAS, MAAA
Found evidence of litigiousness and pervasive overbilling among medical providers – DCC as % of Premium has grown significantly (NAIC)
2008 – 6,3782009 – 6,7262010 – 7,026
Claim Severity is > twice for downstate
Claimants Visited Physical Therapy more than 50 times
18% downstate vs. 10% upstate
Claimants visited Chiropractors > 50 times
19% NYC area vs 21% upstate
12% NYC area vs 19% upstate
Surprisingly, for most types of providers submitting charges above the fee schedule was more prevalent for upstate.
Chiropractors – 59% upstate vs 51% NYC area
Costs insurers’ incur to review and adjust medical bills is considerable.
Examples – electrical muscle stimulation (EMS) units,
transcutaneous electrical nerve stimulators (TENS) units, etc
Even though there is high attorney involvement, claimant lawsuits are rare.
Claims with appearance of buildup - if any element (medical expense, lost wages, or other expenses) was thought to inflated
appearance of buildup -14% NYC vs 4% upstate
35% NYC area claim abuse – fraud or buildup 8% upstate
Reviewed claims in IRC report included Abused Claims that were paid – insufficient evidence to prove fraud or buildup.
-- Adjusting claims
When do you order IME’s? Peer reviews?
How large a bill or expense should be challenged?
Which disputes do you research and how much?
Does the insurance department know about these differences? Yes. How do they respond?
Probably organized rings.
smart, ingenious approaches to accidents
Are they associated with a medical provider, attorney, etc????
Section 1 – Define “health service provider”