The Challenge of Proving Therapy Necessity
In the No-Fault system, physical therapists carry the legal burden of proving their services are medically necessary. Your care is fundamental to recovery, restoring function through targeted therapeutic exercise, manual therapy, and modalities. However, insurers often dispute the need for your skilled services, claiming treatment is excessive, not goal-oriented, or that the patient has plateaued.
Our Solution: Documenting the Functional Recovery Pathway
Choudhry & Franzoni Law Group champions physical therapists. We build a compelling case by compiling your initial evaluation with objective baseline measurements, detailed progress notes, and re-evaluation reports. We demonstrate how each treatment phase directly addressed specific functional deficits caused by the accident, translating your clinical work into a legally persuasive narrative of necessity.
Deconstructing Denials for Physical Therapy
Fee Schedule Denials
We challenge incorrect coding and misapplied fee schedule reductions for your therapeutic procedures, evaluations, and modalities, ensuring proper reimbursement.
Fee Schedule and Unit Limit Disputes
We meticulously challenge denials based on incorrect coding and the misapplication of New York’s No-Fault fee schedules to your therapeutic procedures, modalities, and evaluations. A critical and frequent point of contention is the enforcement of the 12 unit per day limit, a combined cap that applies to all physical medicine services delivered to a patient on a single date of service. When a patient receives care from both a physical therapist and a chiropractor on the same day, insurers will often deny units that exceed this shared limit, typically rejecting the later submitted claim. We expertly navigate these complex allocations. We analyze the timing of service submissions, the justification for the combined treatment plan, and advocate for the proper apportionment of units to ensure you are reimbursed for all medically necessary and rightfully delivered care.
Peer Review Denials
We dismantle reports from non-specialist reviewers, highlighting their lack of understanding of PT standards of care and their disregard for your documented objective functional improvements.
IME Denials
We counter IME reports that contradict your longitudinal findings, emphasizing the limited scope of a single exam versus your ongoing assessment of functional progress.
Allegations of Overutilization
We defend your care plan by presenting documented, measurable goals and clear rationale for treatment duration and frequency.
Our Process for PT No-Fault Arbitrations
We manage the legal process. To build your case, we gather:
- Assignment of Benefits forms and denial letters
- Your complete billing ledger
- Initial evaluations, daily SOAP notes, and re-evaluation reports
- All relevant medical records and referrals
- Any insurer IME or peer review reports
Let Us Handle Your Arbitration
If your necessary physical therapy services have been wrongly denied, you have the right to dispute the decision. Seek experienced legal support to review your claim, file an appeal, and pursue the proper steps to recover the revenue you are entitled to receive.
