NYS Workers’ Compensation & No-Fault Cases

NYS Workers’ Compensation & No-Fault Cases

The Good, the Bad and the Ugly

John A. Sorrentino, D.M.D.

Agreeing to do a workers’ compensation or no-fault case can be a great practice builder and have a powerful and positive impact on the lives of people who have been devastated by a workplace or automobile accident. Yet, many practitioners hesitate or refuse to do these kinds of cases for a variety of reasons. Often, you are dealing with insurance companies that are unfamiliar with dental claims. Perhaps because these claims don’t crop up often, you are not familiar with the process, or you have heard stories of poor, or even no reimbursement.

I got my start learning the process when as a new dentist, one of my patients was involved in a motor vehicle accident and I saw it as an opportunity to help him. What follows is certainly not a complete guide, but over my career, I have completed many cases, which allows me to offer my experiences and the mixed results I have had.

The Good

The rules of workers’ compensation and no-fault claims are such that your compensation is 100% insurance reimbursement. The patient has zero out-of-pocket expenses. Every case has a specific claim ID and a company representative who is assigned to that case. You most likely will be dealing with the same person throughout the process, and claims are processed using the ADA dental claim form.

By law, insurers have 30 days to pay electronic claims and 45 days to pay paper claims, as long as the claim is not disputed. Claims must be denied within 30 days of receipt by the insurer. If additional information is needed from the provider in order to adjudicate a claim, the information must be requested within 30 days of receipt of the claim.

Carriers will pay for copies of the documentation you submit, and New York State law allows you to charge for those copies. They often pay for procedures that most regular dental insurance will not. Often, these types of cases involve lawsuits. Your records are legal documents that attorneys from both sides will want to review. Take before and after photos of everything. They not only provide important documentation, but you will be compensated for all of them. Treatment procedures covered include things like models, local anesthesia codes D9211, D9215, and occlusal adjustment, codes D9951 and D9952.

While some companies, especially those based out of state, may try to negotiate the fees for treatment, you are not obligated to do so. New York State has a set dental fee schedule that applies to both workers’ compensation and no-fault insurance claims reimbursement. A copy of the fee schedule is available on the Workers’ Compensation Board website (https://www.wcb.ny.gov/content/main/hcpp/dentalFeeSchedule.jsp).

NYSDA members may also obtain a copy from the NYSDA office by calling (800) 255-2100, ext. 250. The fee schedule will give you a general idea of what your reimbursement will be. Implants and other major restorative services are covered, as long as they are related to the accident.

New York State and municipal public sector workers are covered by the New York State Insurance Fund (NYSIF). This is a self-funded state program that bears special mention. NYSIF is one of the easiest companies I have ever worked with. Many New York State public sector employees, such as peace officers and correctional officers, may experience dental trauma in their line of work. NYSIF will take predeterminations and claim submissions via email. They are usually very fast and in my experience, predeterminations and claims are adjudicated in a week or two.

The Bad

The rules of workers’ compensation and no-fault claims are such that your compensation is 100% insurance reimbursement. You cannot balance bill the patient. Although there are mechanisms for appeal when a claim is denied, and depending on whether you accepted an assignment of benefits (no-fault cases), if you misjudge what the compensation will be or if your appeal is unsuccessful, there may be no further recourse. Although the same fee schedule is used, both workers’ compensation and no-fault are subject to different policies. No-fault is regulated by the Department of Financial Services (DFS).

Sometimes, especially with motor vehicle accidents, you are dealing with an insurance company that has no knowledge of the dental market or the codes we use. One time, the insurance company paid my fee according to a pre-estimate. While I completed the case in a timely manner, this could have caused legal problems if I had failed to do so, or if the patient chose not to complete treatment. Once again, I attribute this to the company not being familiar with dentistry.

The fee schedule, which is set by the Workers’ Compensation Board, has not been updated since 2009, so be sure to review it before you start. Occasionally, you may have your clinical judgment questioned by an adjuster who does not know anything about dentistry.

The Ugly

The rules of workers’ compensation and no-fault claims are such that your compensation is 100% insurance reimbursement. There is no guarantee that the insurance company has any idea how dental coding and reimbursement work. One time, I had a company reimburse the patient instead of the office. The patient then proceeded to pocket the money and never returned our calls.

A more recent snafu occurred when one company, despite my NPI clearly on the claim form, sent the payment to the “Regent of California” instead of to my office. When the claim involves a company that does not have an affiliation in New York State, you have little recourse. I finally got reimbursed, but it took eight months.

No-fault claims are generally reimbursed by automobile insurance companies. Workers’ compensation plans are purchased by employers and may be self-funded or by a company that does not have a presence in New York State. The workers’ compensation program is governed by the New York State Workers’ Compensation Law, and the regulations are established by the Workers’ Compensation Board (WCB), which administers the program.

In my dealings with both the WCB and DFS, I have found their representatives to be professional, attentive, and they tend to return messages in a timely manner. They are at their best when dealing with in-state and automobile insurance companies. They may not be as much help when dealing with an out-of-state entity.

For the Good of the Patient

In my career, I have always tried to do what is best for my patients. Providing the best treatment you are capable of is only the starting point. We should not shy away from having to do a bit more paperwork or spend a little more time when a patient has been the victim of an unfortunate accident. We are not only restoring their health but their dignity as well. This is why I have found that the process is generally worth the effort. Rebuilding the smile of someone who has been devastated by trauma is one of the most rewarding things a dental practitioner can do. In the end, I would say that the good far outweighs the bad and the ugly.

If you have questions about the New York State workers’ compensation or no-fault programs, contact NYSDA at (800) 255-2100, ext. 250.

Dr. Sorrentino is a member of the NYSDA Council on Dental Benefit Programs representing the Ninth District Dental Association. He has a private practice in Hopewell Junction and is also employed by the New York State Office of Children and Family Services, providing dental services to incarcerated youths.