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CPM – now it is up to DFS and WCB to address the problemJuly 7, 2018

Matter of Global Liberty Ins. Co. v ISurply, LLC, 2018 NY Slip Op 04961 (1st Dept. 2018)

The CPM saga came down to the  2014 letter addressing an inquiry from an insurance carrier and a 2016 letter that was responsive to an inquiry from a prominent plaintiff no-fault attorney.  The Court did not care about informal DOH opinions and WCB opinions, or the famous “FAQ” that appeared to override the 2016 letter.

Sadly, this issue has been playing out for about 6 years, mostly in arbitration.  It has had some action in the Courts, but more sporadic.  From my vantage point, the issue needed an end date.  It made no sense to have a purely legal issue bouncing back and forth in probably over 100,000 awards and court decisions.

First, for those who have questioned “what is CPM/CTU”, it is post-rehabilitative machinery that is supposed to increase healing and functionality following extremity surgery.  It is rented from about a 30-60 day period depending on the provider/supplier.  The equipment wholesales for between $6,000-$10,000.  If I am wrong, correct me – I do not have an invoice in front of me.

The rental rate that has been accepted in arbitration and court is $85-$100 per day.  The item as a 2-3 year useful life.  Again, this is what I have heard. It could be more.

therefore, assuming the equipment is used 320 days per year for 3 years, this would yield a billable value of close to $100,000 for the life of the machine.  Not bad for a $6000 investment.  And now you see the genesis of the frustration some of the pragmatists in no-fault have with what is happening here.

The Appellate Division, although couching the decision in terms of rationality held as matter of law that reimbursement shall be at the value of the rental to the general public.  Of course, nobody rents these machines on a cash basis, this there is no accurate general public fee absent “Ingenix” that exists.  And, if you want to call Ingenix a true valuation as to the cost to the general public, then you are sadly mistaken.  The Court’s holding:

“Global failed to present sufficient evidence demonstrating that the Department of Health (DOH) had determined a price for these rentals. The July 3, 2014 letter from Joanne Criscione, Senior Attorney for the Bureau of Health Insurance Programs Division of Legal Affairs for the DOH appeared to indicate that DOH had adopted “a medicaid reimbursement policy for durable medical equipment (DME) rental items that have not been assigned a Maximum Reimbursement Amount (MRA). For DME items that do not have a MRA, the rental fee is calculated at 1/6th of the equipment provider’s acquisition cost.” In her June 8, 2016 letter, however, she makes clear that her July 3, 2014 letter “was not a determination by the Department of Health area office establishing the reimbursement rate” and she “merely state[d] the Medicaid reimbursement as that policy is set forth in the Medical Provider Manual for DME.” None of Global’s other evidence establishes that DOH had adopted the “1/6th of the equipment provider’s acquisition cost” rate.

It is true that the Medicaid DME fee schedule, which listed certain codes for DMEs, some of which had a MRA and some of which did not, established that for those that did not have a MRA, the monthly rate of 1/6th of the equipment provider’s acquisition cost would apply. And it is also true that, pursuant to 12 NYCRR § 442.2(b), “the total accumulated monthly charges shall not exceed the fee amount allowed under the Medicaid fee schedule.” However, it was not irrational for the arbitrator to conclude that this 1/6th rate applied only to items which had codes listed in the Medicaid fee schedule, which the CPM and CTU at issue here did not. Therefore, as Global neither demonstrated that DOH had adopted the 1/6th rental fee guideline, or that DOH had otherwise determined a rental fee, it was not irrational for the arbitrator to conclude that the reimbursement rate would be “the monthly rental charge to the general public” (12 NYCRR 442.2(b).”

Now, it is up to DFS and WCB to finally address this issue.

One more thing.  Many of you out there are unaware of this, and I was not going to share until this opinion was published.  But, WCB has already ruled on this issue, and I suspect this is what prompted the FAQ:

In the Matter of Long Island DDSO, 2016 WL 7010143 (2016):

“As for the amount for the durable medical equipment, the valuation of durable medical equipment is not within the MTG. This is left to the Board’s Fee Schedule, which references the NYS Medicaid DME Services Fee Schedule.
The rental for the continuous passive motion machine is properly billed as E0936-RR. The Medicaid fee schedule does not contain an entry for this billing code. 12 NYCRR 442.2 (DURABLE MEDICAL GOODS FEE SCHEDULE)” provides:
(a) The maximum permissible charge for the purchase of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances shall be the fee payable for such equipment or supplies under the New York State Medicaid program at the time such equipment and supplies are provided, except that the fee for bone growth stimulators (HCPCS codes E0747, E0748 and E0760) shall be paid in one payment and not split. For orthopedic footwear or if the New York State Medicaid program has not established a fee payable for the specific item, then the fee payable, shall be the lesser of:
(1) the acquisition cost (i.e. the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%; or
(2) the usual and customary price charged to the general public.
(b) The maximum permissible monthly rental charge for such equipment, supplies and services provided on a rental basis shall not exceed the lower of the monthly rental charge to the general public or the price determined by the New York State Department of Health area office. The total accumulated monthly rental charges shall not exceed the fee amount allowed under the Medicaid fee schedule.
(c) The maximum permissible charge for the purchase of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances and the maximum permissible monthly rental charge for such equipment, supplies, and services provided on a rental basis as set forth in subdivisions (a) and (b) of this section are payment in full and there are no separate and/or additional payments for shipping, handling, and delivery.
As there is no fee schedule for the continuous passive motion machine, SIF is liable to reimburse the provider in accordance with “the usual and customary price charged to the general public” and that this amount “shall not exceed the lower of the monthly rental charge to the general public or the price determined by the New York State Department of Health area office.”
Therefore, upon review of the record and based upon a preponderance of the evidence, the Board Panel finds that the record supports finding the C-8.1(B) in favor of the provider, to the extent that the SIF is liable for payment for a three-week rental of the continuous passive motion machine at the usual and customary price charged to the general public. Any unpaid balance shall not be the responsibility of the claimant.

Time for action on this issue now!

 

 

One Response

  1. Alan M. Elis says:

    I’ve been arguing the long island ddso case since september 2017.

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