In New York State, the Health Insurance Matching Program – widely known as HIMP – provides means for a claimant’s private health insurer to seek reimbursement for treatment they believe a workers’ compensation carrier or self-insured employer should have paid.

The exposure from a single HIMP-1 claim can range from hundreds to hundreds-of-thousands of dollars, and the volume of claims is rising rapidly. But you have options other than automatically paying those claims.

Understand the HIMP Process

• The HIMP process is governed by specific sections of the Workers’ Compensation Law and NYCRR regulations.
• The process begins with health insurers submitting requests for a match, including detailed claimant information. The New York Workers’ Compensation Board then determines if there is a full or partial match based on the data provided.

Be Sure the HIMP-1 Form is Complete

• The HIMP-1 form is crucial for initiating, litigating, and concluding HIMP claims. It must be filled out accurately, especially if a full match has been obtained from the Board.
• Key fields include the claimant’s name, date of loss, and other identifying information. If the form lacks sufficient details, it may indicate a fishing expedition rather than a legitimate claim.

Track Timeliness and Documentation

• HIMP claims are governed by two separate timeliness thresholds. A match must be obtained from the Board within three years of the date of payment for treatment. Thereafter, only after a full match is obtained, the health insurer must serve the demand on the workers’ compensation carrier no more than one year from the latest of ANCR/acceptance, match date, or date of payment for treatment.
• Health insurers must provide all the information listed in Section 325-6.3(c) of the HIMP Rules and Regulations with their demand, including all of the data received from the Board after obtaining a “full match,” the completed HIMP-1 form, itemized paid expenses (amount billed, amount paid, ICD10 and CPT/DRG codes), proof of ANCR/acceptance, and proof of service.

Use Permissible Objections

• There are specific objections that can be raised against HIMP claims, such as untimely service, lack of causal relationship, treatment inconsistent with the Medical Treatment Guidelines, and fees exceeding the New York State Workers’ Compensation Medical Fee Schedule.
• A list of specific objections can be found in 12 NYCRR 325-6.4(b) and on Part II of the HIMP-1 form. Objections should be written on PART II of the form and should be supplemented with evidence.
• Certain objections are prohibited, including failure to file the required notices by the provider and treatment being too excessive or frequent unless inconsistent with Guidelines. Understanding these distinctions is crucial for effectively managing HIMP claims.

Consider Arbitration and Appeals

• If disputes arise, the arbitration process is handled by the American Arbitration Association (AAA). Both parties can request an oral hearing, and the arbitrator can determine the eligibility of the case for arbitration.
• Grounds for appeal are governed by Article 75 of the CPLR in New York Supreme Court, with the most common ground being that the arbitrator exceeded his power or so imperfectly executed it that a final and definite award upon the subject matter was not made. These appeals are rarely successful, with New York courts favoring alternative dispute resolution (ADR).

Avoid Routine Payment

• Never pay a HIMP demand without assessing its legitimacy first. At minimum, the Medical Fee Schedule applies as an objection to almost every HIMP claim.
• Don’t delay! Objections must be served within 90 days of the HIMP-1 demand, or almost all viable objections are waived.
• To cut down your exposure, consider pursuing “global settlements” to resolve bulk HIMP batches if you are receiving multiple demands simultaneously. Often the health insurer/HIMP agent will be willing to work out a total demand amount in a give-and-take conversation across individual claims.

Goldberg Segalla’s dedicated HIMP-1 defense team can help you anticipate and respond to a HIMP-1 exposure and prepare a comprehensive defense plan on your behalf. From developing and serving formal objections to negotiating settlements when warranted or appearing before the American Arbitration Association, our experience in the arena of HIMP-1 Workers’ Compensation defense runs deep. We stand ready to help you navigate this often-complicated process.

For questions or immediate assistance, please contact:

• Christopher J. Major
• Jonathan D. Mallozzi