New York’s Health Insurance Matching Program (HIMP) allows health insurers and health benefit plans to seek reimbursement when they pay medical expenses that should have been covered through a patient’s workers’ compensation claim. When a workers’ compensation carrier or self-insured employer receives a HIMP reimbursement request, it must determine whether the request is valid and either reimburse the health insurer or raise an appropriate objection within the applicable deadline. An attorney experienced in the New York Workers’ Compensation Law can evaluate each demand, preserve valid objections, and mitigate liability.
What is HIMP in New York?
HIMP is a reimbursement system established under New York Workers’ Compensation Law §§ 13(d) and 13(h). It applies when a health insurer, health benefits plan or other payor of health benefits pays for medical or hospital services that may instead be the responsibility of the workers’ compensation insurance carrier for the injured worker’s employee.
The program uses a matching process to identify potential overlaps. A health insurer submits information about medical payments for comparison with the Workers’ Compensation Board records. When the information produces a full match, the health insurer may pursue reimbursement from the responsible workers’ compensation carrier or self-insured employer.
A full match, however, does not necessarily establish that every medical expense submitted by the health insurer is related to a workers’ compensation claim and must be reimbursed.
How Does a Health Insurer Request HIMP Reimbursement?
A health insurer initiates a claim for reimbursement by submitting information for a HIMP search. To preserve eligibility for arbitration, the insurer must comply with HIMP requirements governing when medical payment information is submitted and matched to a workers’ compensation claim.
After receiving a full match, the health insurer may serve a Form HIMP-1 requesting reimbursement. The request must contain supporting information concerning the payments at issue, including relevant treatment and billing information. Reimbursement is generally based on the amount actually paid by the health insurer, subject to applicable workers’ compensation fee schedules and other statutory limitations.
How Long do Carriers and Self-Insured Employers Have to Respond?
A workers’ compensation carrier or self-insured employer that intends to object to a HIMP reimbursement request has 90 days after service of the HIMP-1 to serve its objection on the health insurer.
The objection must identify the grounds for disputing reimbursement and include appropriate supporting documentation. Missing the response deadline limits the objections that may later be raised if the dispute escalates to arbitration.
Certain HIMP deadlines may be extended by written agreement between the parties. Without such an agreement, carriers and self-insured employers should treat the applicable response period as a firm deadline.
What Grounds May Support an Objection to a HIMP Claim?
A full match identifies a potential reimbursement obligation, but the carrier or self-insured employer is allowed to review whether the individual expenses are properly payable under workers’ compensation.
Depending on the circumstances, grounds for objection may include:
- The workers’ compensation claim has not been established as compensable
- The reimbursement request was not timely or properly submitted
- The treatment concerns a condition or body part unrelated to the established workers’ compensation claim
- The requested amount exceeds the applicable workers’ compensation fee schedule
- The treatment is inconsistent with applicable Workers’ Compensation Board Medical Treatment Guidelines
Not every defense that might arise in the underlying workers’ compensation case is necessarily available in a HIMP dispute. Reviewing the specific request against the governing HIMP rules is therefore important before an objection is served.
What Happens When a HIMP Claim Is Disputed?
When a carrier or self-insured employer objects and the health insurer continues to seek reimbursement, the dispute may proceed to arbitration. HIMP reimbursement disputes are handled through the American Arbitration Association rather than adjudicated by the Workers’ Compensation Board.
The health insurer has 90 days after service of the objection to request arbitration. At that point, the documentation supporting the reimbursement request and the objections raised in the initial response can become central to the dispute.
A HIMP-1 should not be treated as routine medical billing correspondence. How the request is reviewed and answered can affect the carrier’s or self-insured employer’s position if arbitration follows.
How Can Carriers and Self-Insured Employers Manage HIMP Claims?
Effective HIMP claim handling starts with recognizing reimbursement requests quickly and routing them to the appropriate claims professional.
The HIMP-1 should be compared with the underlying workers’ compensation file, with particular attention to:
- Accepted body parts and medical conditions
- Dates and nature of treatment
- Amounts paid and applicable fee schedules
- Supporting medical and billing documentation
- Prior payments or reimbursements
- Compliance with HIMP procedural requirements
This review may uncover charges associated with unrelated treatment, duplicate payments or other issues that affect the amount of reimbursement claimed.
Respond to HIMP Claims With the Right Strategy
HIMP gives health insurers a mechanism to recover medical expenses that properly belong within the workers’ compensation system. It does not, however, require workers’ compensation carriers and self-insured employers to reimburse every expense presented without review.
With response deadlines and specific grounds for objection governing the process, early evaluation can help preserve available defenses and prevent unsupported expenses from being shifted to a workers’ compensation claim.
Stewart, Goldsmith & DeCurtis, LLP represents workers’ compensation carriers and self-insured employers throughout New York, including in matters involving HIMP reimbursement and arbitration. Contact us today to discuss a HIMP reimbursement request, potential objection or other workers’ compensation defense matter.