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+15 minute decision begs a better questionJune 25, 2018

Karina K. Acupuncture, P.C. v Phoenix Ins. Co., 2018 NY Slip Op 50913(U)(App. Term 1st Dept. 2018)

“Defendant made a prima facie showing of entitlement to summary judgment dismissing plaintiff’s no-fault claims for acupuncture needle reinsertion services by demonstrating that it timely and properly denied the claims based on the assignor’s sworn statement denying that such services were performed upon him. In opposition, plaintiff’s proof, essentially consisting of an attorney’s affirmation, was insufficient to raise a triable issue as to whether the needle reinsertions were actually performed.”

What happens when the EIP says “sometimes” I get reinserted needles?  Or the proof is inconclusive that the EIP never had the needles reinserted.  Does the provider lose all reinsertion billing or does the carrier lose the defense because it cannot delineate the dates the reinsertion never occurred.

This question asks whether submitting a false bill in the first instance carriers the penalty of losing out on all false billing (even if some of the false billing is not false).  Since the “fraud” provision of the general policy does not apply to the no-fault endorsement (Utica v. Timms), I am hard pressed to say the defense would exist in what I think is the circumstance that occurs more frequently.