Raz Acupuncture, P.C. v AIG Indem. Ins. Co., 2010 NY Slip Op 51177(U)(App. Term 2d Dept. 2010)
It gets to the point where enough is enough. The Appellate Term, Second Department, has repeatedly held that acupuncture services are reimbursable, as a matter of law, at the chiropractor rate. The Court in the case stated the following:
“This court has held, “as a matter of law, that an insurer may use the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which a licensed acupuncturist is entitled to receive for such acupuncture services” (Great Wall Acupuncture, P.C. v Geico Ins. Co, 26 Misc 3d 23, 24 [App Term, 2d, 11th & 13th Jud Dists 2009]). As it is undisputed that defendant paid plaintiff based upon the workers’ compensation fee schedule for acupuncture services performed by a medical doctor, a rate higher than that established for acupuncture services performed by a chiropractor, we decline to disturb so much of the order as granted defendant summary judgment dismissing plaintiff’s complaint with respect to those claims.”
What is somewhat new is that the Appellate Term has held that the “it is not compensable” defense for failing to pay an initial acupuncture visit shares the same level of validity as the “it is included in the comprehensive visit” defense for failing to pay for computerized range of motion. For those of you who do not get this sardonic humor, it is sufficient to say that there is no validity to this statement.
Another case where the Appellate Term seems to hold that a triable issue of fact is raised regarding the compensability of range of motion testing
First Aid Occupational Therapy, PLLC v Country-Wide Ins. Co., 2010 NY Slip Op 50594(U)(App. Term 2d Dept. 2010)
“Defendant also established that it had timely denied the two $182.84 and three $523.20 claims on the ground that the services for which payment was sought were part of another service and, thus, were not separately reimbursable (see St. Vincent Med. Care, P.C. v Country-Wide Ins. Co., 26 Misc 3d 58 [App Term, 2d, 11th & 13th Jud Dists 2009]), and defendant’s opposition papers were sufficient to raise a triable issue of fact with respect thereto. Consequently, neither party was entitled to summary judgment on the first, seventh and eighth causes of action, as well as so much of the third cause of action as sought to recover upon the $523.20 claim.”
I have posted on this issue previously. Again, I do not generally believe that the range of motion testing is included in the office visit as the insurance carrier has been arguing in these cases.
St. Vincent Med. Care, P.C. v Country Wide Ins. Co., 2010 NY Slip Op 50488(U)(App. Term 2d Dept. 2010)
1. Fee Schedule
“While defendant argues that the Civil Court improperly awarded plaintiff summary judgment as to its seventh cause of action since defendant timely denied that bill on the ground that the fees charged were excessive and not in accordance with the Workers’ Compensation fee schedule, defendant did not annex any proof to establish said defense. Consequently, defendant failed to establish the existence of an issue of fact with respect to this cause of action.”
This is probably regarding a global denial based upon range of motion testing being considered part of the initial visit. I do not know this for sure, but this seems to be a common theme between these parties and the attorneys representing them. Today, the Appellate Term properly held that an issue of fact was not raised. On some days, they hold a triable issue of fact is raised when similar proof is presented. On other days, they hold similar to that of this case.
2. Appeals from interlocutory judgments
“Defendant also argues that the Civil Court improperly denied its cross motion for summary judgment as to plaintiff’s tenth cause of action because plaintiff failed to rebut defendant’s prima facie showing of lack of medical necessity as to this cause of action. However, since defendant did not appeal from the underlying order and the appeal from the judgment does not bring up for review so much of the order as denied the branch of defendant’s cross motion seeking summary judgment dismissing plaintiff’s tenth cause of action, said part of the order is not before us on appeal.”
It took me a bit to figure this out. A final judgment always brings up for review the underlying non-appealed interlocutory orders. In this case, an interlocutory judgment was issued, since the judgment did not encompass the entire action. Rather, it encompassed everything except the medical necessity cause of action. Therefore, absent an appeal of the order denying summary judgment, Defendant can only appeal from the final judgment. The final judgment would occur following the trial. At that point, an appeal of the final judgment would bring up for review the order denying summary judgment.
Do you understand?
St. Vincent Med. Care, P.C. v Country-Wide Ins. Co., 2010 NY Slip Op 50444(U)(App. Term 2d Dept. 2010)
“Defendant also established that it had timely denied the two $365.68 claims (plaintiff’s fourth and seventh causes of action) on the ground that the services for which payment was sought were part of another service and, thus, were not separately reimbursable. Consequently, defendant raised a triable issue of fact with respect to the fourth and seventh causes of action (see St. Vincent’s Med. Care, P.C. v Country-Wide Ins. Co., ___ Misc 3d ___, 2009 NY Slip Op 29508 [App Term, 2d, 11th & 13th Jud Dists 2009]).”
Compare, First Aid Occupational Therapy, PLLC v Country-Wide Ins. Co., 2010 NY Slip Op 50149(U)(App. Term 2d Dept. 2010), which I discussed here.
Same facts, yet different result than that found in First Aid Occupational Therapy, PLLC.
Range of Motion (ROM) and Manual muscle (MM) testing are compensable services, and the argument raised in the above cases lacks merit. What you must understand, however, is that MM is limited to being billed as one unit at either CPT Code 95833 or CPT Code 95844. It cannot be billed at 95831 * each body part. ROM is per body section, and can be billed numerous times, subject to other collateral issues that are out there. You can contact me if you want my other thoughts.
First Aid Occupational Therapy, PLLC v Country-Wide Ins. Co., 2010 NY Slip Op 50149(U)(App. Term 2d Dept. 2010)
Unbundling. I love this word. I discussed this issue in a previous post. Click here for that post. The only difference between the previous case and this case is that the penalty for failing to proffer an expert affidavit (assuming you can find an expert who would support the unbundling theory in this case) is succumbing to a plaintiff’s summary judgment motion. The relevant portions of the case are as follows:
“While defendant denied the claims underlying plaintiff’s first and fifth causes of action on the ground that plaintiff sought to recover in excess of the fee schedule by ” unbundling’ the service[s] into . . . separate bill[s]” even though such services “are considered part of the initial medical evaluation,” defendant did not submit an affidavit from someone with sufficient expertise to establish that ground as a matter of law or even to demonstrate the existence of a triable issue of fact with respect to the billing for such services (see Zuckerman v City of New York, 49 NY2d 557 ; Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co., 61 AD3d 13 ). As a result, defendant “failed to raise a triable issue of fact in admissible evidentiary form sufficient to warrant denial of summary judgment in favor of [plaintiff] on the [first and fifth] cause[s] of action” (Kingsbrook Jewish Med. Ctr., 61 AD3d at 23).”
Finally, the case involved a premature additional verification request where plaintiff was granted summary judgment. This was reversed.
“It is undisputed that defendant timely mailed its initial requests for verification and that plaintiff failed to provide the information requested. Plaintiff also did not provide the information requested in defendant’s follow-up verification requests, which were mailed on the 30th day after the initial verification requests but prior to the expiration of the full 30-day period within which plaintiff was supposed to respond to defendant’s initial requests for verification. As the foregoing facts are nearly identical to those in Infinity Health Prods., Ltd. v Eveready Ins. Co. (67 AD3d 862 ), “the 30-day period within which the defendant was required to pay or deny the claim did not commence to run . . . [and] plaintiff’s action is premature” (id. at 865).”
St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. 2009 NY Slip Op 29508 (App. Term 2d Dept. 2009)
This case is more notable for the fact that it was decided prior to, yet published after “Infinity v. Eveready”, as well as Justice Golia’s scathing dissent regarding many of the same concerns that the Court of Appeals discussed 6 years ago in “Medical Society v. Serio.”
The issue that I am writing about is something that I am sure nobody noticed. It involved the defendant’s failure to prima facie prove its fee schedule defense. The court said the following:
“In opposition, defendant argued that it timely denied plaintiff’s claim seeking to recover the sum of $228.55 for services rendered on February 22, 2006 on the ground that the fee sought was in excess of the amount permitted by the workers’ compensation fee schedule because the services for which payment was sought were part of another service and, thus, were not separately reimbursable. Defendant established that it timely denied this claim”
It appears that the insurance carrier denied either muscle testing or range of motion testing based upon the worker’s compensation ground rule that prohibits compensation for certain services that are performed when an initial or follow-up evaluation is performed and paid. While many do not know this fact, this was the fee schedule issue that was presented in Rogy Medical, P.C. v. Mercury Ins. Co., 2009 NY Slip Op 50732(U)(App. Term 2d Dept. 2009), and it did not succeed.
The matter of Great Wall Acupuncture, P.C. v Geico Ins. Co. 2009 NY Slip Op 29467 (App. Term 2d Dept. 2009) was an interesting opinion involving acupuncture fee schedule cases. This case completes the equation as to what is necessary for an insurance carrier that pays the chiropractor rate for acupuncture to prevail at trial. Upon showing that acupuncture services were paid at the chiropractor rate, a prima facie defense as a matter of law has been satisfied.
Thus, as long as the pertinent portions of the fee schedule and a timely denial are in evidence, a defense verdict should be granted. There is nothing that a plaintiff can do to rebut this prima facie showing.
Here are the pertinent portions of the opinion with some relevant observations.
“At trial, the parties stipulated to plaintiff’s prima facie case and further agreed that defendant had timely denied the unpaid portion of the claim on the ground that the charges for acupuncture treatments exceeded the maximum fees under the appropriate
fee schedule. Additionally, pursuant to the parties’ stipulation, the claim form and the denial of claim form were admitted into evidence”
- This portion of the opinion discusses the evidence that in the Appellate Term’s opinion was sufficient to make a prima facie demonstration that the acupuncture services were billed in excess of the chiropractor fee schedule.
“A person who seeks to practice acupuncture must be either licensed (Education Law § 8214) or certified (Education Law § 8216) to do so (see Education Law § 8212). The training to obtain a license remains the same even if the person seeking to practice acupuncture has a license in a different profession, such as a chiropractic license (see 8 NYCRR 52.16 [b]; cf. 8 NYCRR 52.16 [a]).”
- Here, the Appellate Term outlined the comparative licensure requirements between a licensed acupuncturist and a chiropractor licensed to practice acupuncture. I would just note that Judge Gonzalez in Great Wall Acupuncture v. GMAC, 6/15/2007 N.Y.L.J. 22, (col. 3)(Civ. Ct. Bronx Co. 2007) engaged in a similar analysis, and came to a somewhat differing conclusion.
“Accordingly, in light of the licensure requirements, we hold, as a matter of law, that an insurer may use the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which a licensed acupuncturist is entitled to receive for such acupuncture services”
- All the insurance carrier needs to show is that the services were paid at the chiropractor acupuncture rate and a directed verdict in favor of an insurance carrier must be granted.
Hopefully, we will never see the words reasonable geographic value, or some variant of this phrase, ever again.
The Appellate Term in Great Wall Acupuncture, P.C. v GEICO Ins. Co. 2009 NY Slip Op 52308(U)(App. Term 2d Dept. 2009) once again held that the chiropractor fee schedule was all that a licensed acupuncturist was entitled to. Sure, the court modified the lower court order on the basis that summary judgment should have been granted to plaintiff on the untimely denied portion of the complaint. The Court also categorically rejected the reasonable geographic charge argument that plaintiff forwarded. Finally, the court even affirmed the lower court’s granting of summary judgment to the non-moving party, Geico.
So, despite the order of the lower court being modified, I must offer my congratulations to (I am going to guess) Spina’s office on this one.
Getting off the topic, how many of you have done an EUO and asked the EIP whether the acupuncturist missed the meridian and caused the EIP to bleed? I usually ask that question, and you would be surprised at the amount of affirmative responses I get.
The Appellate Term is starting to sound like a broken record. Yet, each time they play the record it seems that the message is more emphatic.
In New Wave Acupuncture v. Geico, 2009 NY Slip Op 52211(u)(App. Term 2d Dept. 2009), the Court stated the following: “For the reasons stated in Great Wall Acupuncture v GEICO Gen. Ins. Co. (16 Misc 3d 23 [App Term, 2d & 11th Jud Dists 2007]), it was proper for defendant to use the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which plaintiff was entitled to receive.”
Note: The court as of this case and Ava Acupuncture v. Geico does not require the carrier to provide evidence as to why it chose to pay chiropractor fee schedule rate as opposed to another rate. The chiropractor fee schedule amount is acceptable as a matter of law. Period, the end.
Now, let’s assume that you are in a stipped in trial and the sole issue is whether or not the billing was in accordance with the “fee schedule”. Based on New Wave Acupuncture v. Geico and Ava Acupuncture v. Geico, this is what the defendant’s portion of the trial should look like:
Exhibit “A” [Comes in through stip]
(1) Denial of claim form with explanation of benefits
Exhibit “B” [Comes in as a government document through judicial notice Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co, 61 AD3d 13 (2d Dept. 2009)].
(2) Fee schedule with CPT 97810, 97811, 97813, 97814;
Exhibit “C” [Comes in as a government document through judicial notice Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co, 61 AD3d 13 (2d Dept. 2009)].
(3) Chiropractor conversion factor [5.78];
Exhibit “D” for identification:
(4) Shiny Sharpe brand Calculator
Exhibit “E” for reference: New Wave Acupuncture v. Geico and Ava Acupuncture v. Geico
(5) Give copies to the Judge and Plaintiff’s counsel.
(6) Tell Plaintiff and judge: “No, I do not need to bring a claim rep. This is why…”
(7) With calculator, take the relative value, multiply by the Region IV conversion factor of 5.78 and announce the result to the court. If you want, read the portion of the fee schedule that tells the court that this is how you arrive at the compensable amount. You will find this in the introduction section of the fee schedule.
Now, do this for each billed for code. Does the amount you calculated match the amount paid on the denial of claim form? If yes, go to next step.
(7) Motion for directed verdict.
(8a) If win smile
(8b) If lose APPEAL and do not forget to enter a judgment for costs and disbursements including the prospective marshal fee after the judgment is reversed without costs. The without costs only refers to appellate costs.
(8c) Tell the marshal you want to enforce the $105 judgment you just entered. See what the marshal says. I know first hand what you will be told. But, insist that the marshal collects the judgment. He is duty-bound to do this. I guarantee you will have a check in the mail in no time. One warning however: the next time you call that marshal, you will be told that you have the wrong number. Don’t worry – there are plenty of marshals out there.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co.
2009 NY Slip Op 51017(U)
It is amazing that Plaintiffs are still fighting what the proper reimbursement is for acupuncture services that are paid at the chiropractor rate. Some Plaintiffs are still arguing that the “geographic reasonable value” is the proper basis for no-fault compensation. Others are arguing that the defendant’s claims representative needs to affirmatively state that the insurance carrier’s standard practice is to pay claims at the chiropractor rate.
This case holds that reimbursement at the chiropractor rate is proper as a matter of law. Period. No strings, no streamers and no conditional statements to the contrary. From a point of practice, this case only discusses reimbursement under CPT Code 97780. Thus, a case coded with CPT Code 97780 and paid at the physician rate ($42.84) or at the chiropractor rate ($29.30), should allow the insurance carrier to prevail on motion or at trial.
Once the Appellate Term breaks down the proper amount of compensation for CPT Codes 97810, 97811, 97813 and 97814, then the paradigm will be completed.