Important Advisory for Healthcare Providers: Prohibition on the Use of Extrapolation in Medical Necessity Disputes

Category: Client Alerts
Published: January 12, 2024

We would like to remind New York healthcare providers about a significant regulatory aspect that impacts the way private insurers handle medical necessity disputes in New York. This is particularly relevant for those engaged in dealing with insurance audits or adjudicating disputes over medical claims.

Understanding the Principle of Extrapolation
Extrapolation, in the context of insurance claims, refers to a method where insurers analyze a small set of claims and apply their findings to a larger group of similar claims. This technique can lead to broad implications for medical providers, potentially resulting in widespread claim denials or substantial repayment demands.

The Fundamental Rule: Prohibition of Extrapolation in Medical Necessity Disputes
In New York, there is a definitive rule regarding this practice, especially in the context of medical necessity disputes: Insurers are prohibited from using extrapolation to determine the medical necessity of services. This directive is underpinned by the New York State Insurance Department’s interpretation of New York Insurance Law Article 49 and New York Public Health Law Article 49.

Implications for Healthcare Providers
As professionals in the healthcare sector, this regulation implies:
• Each submitted claim must be individually assessed. In cases where an insurer disputes the necessity of a provided medical service, they are obliged to evaluate each claim on its own merits.

You are entitled to a fair and comprehensive review. With the requirement for individual claim evaluation, healthcare providers have a greater opportunity to substantiate the medical necessity of their services on a case-by-case basis.

It is crucial to be cognizant of the fact that while insurers may perform audits on previously submitted claims, they are not permitted to employ extrapolation techniques in disputes concerning the medical necessity of services in New York. This rule is vital for ensuring equitable and individualized assessments of each claim. It is advisable to continue ensuring meticulous documentation and accurate claim submissions to robustly demonstrate the medical necessity of the services you render.