No‑Fault Insurance Claims Recovery for Doctors
Supporting Healthcare Providers with
No‑Fault Billing & Claims
At No Fault Wizard, we specialize in helping medical providers—especially physicians and multidisciplinary clinics—navigate the complexities of New York’s no‑fault insurance system. When insurers deny, underpay, or delay reimbursement for treatments related to auto accidents, doctors need a knowledgeable legal and billing recovery team in their corner.
Table of Contents
Understanding Your No-Fault Benefits
When treating patients injured in motor vehicle accidents in New York, it’s essential for medical professionals to understand how no-fault benefits—also known as Personal Injury Protection (PIP)—function in relation to treatment eligibility and reimbursement.
No-fault insurance in New York is designed to cover “basic economic losses” stemming from accident-related injuries, with a standard coverage limit of $50,000 per person. This includes several categories relevant to your medical billing and treatment authorization process:
Medical Expenses
The majority of no-fault reimbursement is allocated to reasonable and necessary medical services. This includes:
Diagnostic testing (MRI, X-rays, etc.)
Surgical procedures and specialist consults
Office visits and follow-ups
Physical therapy, chiropractic, and acupuncture care
Prescription medications
Durable medical equipment (DME)
Surgical procedures and specialist consults
As a provider, you must ensure that all treatment is medically necessary, well documented, and clearly linked to the motor vehicle accident to qualify for payment.
Lost Wages
Although lost wages are a patient-focused benefit, providers should understand that a patient receiving wage loss compensation through PIP may require ongoing medical justification to support their disability status. This often involves detailed medical reports or disability narrative letters—services which may also be billable under no-fault.
Reimburses 80% of lost income, capped at $2,000 per month for up to three years
Supplemental income benefits may be available from New York State Disability Insurance
Out-of-Pocket Expenses
Patients may claim additional necessary expenses, including:
Transportation to and from medical appointments
Assistance with household tasks due to physical limitations
Other medically justified auxiliary needs
These are reimbursed up to $25 per day for one year after the accident. Providers can support these claims by documenting how a patient’s injuries affect their daily function.
Death Benefit
A one-time $2,000 death benefit is available to the estate of any person who dies as a result of accident-related injuries. While not directly tied to provider billing, awareness of this provision is important when navigating post-mortem record requests or lien discussions.
Why This Matters for Providers
By understanding the scope of no-fault benefits, you can:
Structure your treatment plans to align with reimbursable services
Anticipate documentation demands from insurers or IME reviewers
Support patients in receiving the full range of available benefits
Reduce claim denials by aligning with PIP eligibility requirements from the outset
Our Provider Services
Claim Audit & Re-Billing
Review your medical records and billing data to identify and re‑submit denied no‑fault bills with improved documentation and coding accuracy.
Appeals & Litigation
Handle all stages: demand letters, pre‑litigation appeals, court filings, and enforcement actions on unpaid provider claims.
Legal Compliance & Training
Educate clinical and billing staff on no‑fault documentation best practices, accident‑to‑treatment linkage requirements, and filing timelines.
Provider Advocacy
Negotiate with insurers on provider rate disputes and participate in collective actions or policy advocacy regarding provider compensation in the no‑fault system.
How It works
Initial Provider Consultation
We assess your billing situation and audit outstanding or denied no‑fault claims.
Claim Evaluation & Strategy Planning
We recommend whether to re‑bill, appeal administratively, or sue; we provide estimated recovery timelines and costs.
Documentation Support
Work with your medical and billing team to strengthen charts, SOAP notes, and attestation to link treatment to accidents.
Appeals & Litigation
We send appeals, negotiate with insurers, and if needed, file lawsuits to secure reimbursement.
Final Resolution & Recovery
Once we succeed in recovering full payment (plus interest or fees where possible), we deliver funds and guidance to prevent future denials.
Who Benefits?
Doctors, chiropractors, physical therapists, pain management specialists, diagnostic imaging centers, and multidisciplinary medical practices operating within New York State who treat motor vehicle accident patients under no‑fault insurance.
No Fault Insurance Claims Legal Overview
- Comprehensive Automobile Insurance Reparations Act (Chapter 485 of Laws of 1973): establishes provider billing rights under New York no‑fault insurance
- NY PIP (Personal Injury Protection) statutory cap on Basic Economic Loss: (~$50,000 per accident per person) covering medical treatment, lost wages, and necessary services
- Filing deadlines: provider must submit no‑fault applications within 30 days of treatment or as soon as claimant knows treatment is related; lawsuits against insurer must be filed within 12 months of expense/date of denial
- Ensure proper documentation: clear linkage between accident and treatment, necessity, and continuity of care
- Use of Independent Medical Examination (IME) preparation and rebuttal: strengthening providers’ credibility when insurers dispute necessity
- Appeal and litigation: engage in administrative appeal, then suit on denied or underpaid provider claims, often in Supreme Court actions or delay-of-payment causes of action
- Recovery of full reimbursement for missed or denied medical billing under Basic Economic Loss caps
- Prevailing party may claim interest and delay damages depending on statutory and case law
- In class‑action or aggregation situations, outcomes may include negotiated fee schedules or insurer‑wide payment protocols; precedent-setting decisions guiding future provider billing
Disclaimer: This content is for informational purposes and does not constitute legal advice. Always consult a licensed attorney for advice about your specific provider circumstances.
Frequently Asked Questions
Q: Can doctors sue first-party no‑fault insurers for unpaid medical bills?
Yes — under New York law, providers may bring an action to recover payment for services rendered up to the Basic Economic Loss caps after exhausting administrative steps within specified deadlines.
Q: What if the patient’s no‑fault cap is exhausted?
Once the $50,000 limit is reached, additional costs may shift to private health insurance or patient liability. We can help you explore alternative reimbursement paths.
Q: How long does recovery usually take?
Initial audits and re-billing can resolve many claims within weeks. Appeals or litigation can extend several months depending on insurer responsiveness and court scheduling.