Easy Care Acupuncture, PC v MVAIC, 2016 NY Slip Op 51556(U)(App. Term 1st Dept. 2016)
“While the record reflects that defendant properly paid a portion of the submitted claims for acupuncture services pursuant to the workers compensation fee schedule (see Akita Med. Acupuncture, P.C. v Clarendon Ins. Co., 41 Misc 3d 134[A], 2013 NY Slip Op 51860 [U] [App Term 1st Dept 2013]), triable issues remain with respect to the claims denied in whole or part by defendant on the stated basis that the maximum payment had already been made for the billed codes (see TC Acupuncture, P.C., v Tri-State Consumer Ins. Co., 52 Misc 3d 131[A], 2016 NY Slip Op 50978[U] [App Term, 1st Dept 2016]; Sunrise Acupuncture PC v Tri-State Consumer Ins. Co., 42 Misc 3d 151[A], 2014 NY Slip Op 50435 [U] [App Term 1st Dept 2014]). Defendant’s submission reveals the existence of triable issues of fact as to whether defendant partially exhausted the coverage by payments to another provider, and whether those payments were proper under the insurance department regulations. Defendant’s failure to deny the claim within 30 days does not preclude a defense that the coverage limits have been exhausted (see New York & Presbyt. Hosp. v Allstate Ins. Co., 12 AD3d 579 [2004]).”
Starting backwards, the court questioned the priority of payment regimen. Second, the Court found issues of fact as to the fee schedule reductions. What really happened here?
One Response
Yea, the court’s consistently abide the priority of payments regulation. The AAA does not. Thus, some bills that can be completely recovered in a court action cannot be recovered whatsoever at arbitration. That’s smart.
this issue will be like medical necessity in the 2000’s– should result in a torrent of cases hitting the courts and CONSEQUENT reduction in arbs. It’s probably malpractice to utilize the AAA in scenarios involving late denials and likely policy exhaustion. Let’s see how long it takes the plaintiff’s bar to react to the failure of the no-fault arb scheme.