July 21, 2017

Jaga Med. Servs., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 50954(U))

https://www.beynensonlaw.com/case-law/jaga-med-servs-p-c-v-american-tr-ins-co-2017-ny-slip-op-50954u/

Court: Appellate Term, Second Department
Decided: July 21, 2017
Citation: 2017 NY Slip Op 50954(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 2 later decisions (see Cited by)
Issues: Fee schedule Medical necessity
Legal questions: Lack of medical necessity · Proving a fee schedule defense (see the maps)

Cite as

Jaga Med. Servs., P.C. v American Tr. Ins. Co., 2017 NY Slip Op 50954(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

The insurer proved proper fee-schedule reductions and lack of medical necessity, and the provider failed to rebut the peer review. The insurer's professional coder established that the unpaid portions sought in the first, second and fifth causes of action exceeded reimbursement permitted by the workers' compensation fee schedule. For the sixth through eighth causes of action, a sworn peer review supplied a factual basis and medical rationale for lack of medical necessity. The provider's doctor's affidavit neither meaningfully addressed nor sufficiently rebutted those conclusions. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, denying the provider summary judgment on the first, second and fifth causes of action and granting the insurer dismissal of those and the sixth through eighth causes of action.

Reported in New York Official Reports at Jaga Med. Servs., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 50954(U))

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

Jaga Medical Services, P.C., Lambert, Eva, Appellant,
against
American Transit Ins. Co., Respondent.

The Rybak Firm, PLLC (Damin J. Toell, Esq.), for appellant. Law Office of Jason Tenenbaum, P.C. (Jason Tenenbaum, Esq.), for respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (William A. Viscovich, J.), entered May 16, 2014. The order, insofar as appealed from, denied the branches of plaintiff’s motion seeking summary judgment upon the first, second and fifth causes of action and granted the branches of defendant’s cross motion seeking summary judgment dismissing the first, second, and fifth through eighth causes of action.

ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment. Insofar as is relevant to this appeal, defendant cross-moved for summary judgment dismissing the first, second and fifth causes of action on the ground that these causes of action sought to recover upon the unpaid portions of the underlying claims, which amounts exceeded the amounts permitted by the workers’ compensation fee schedule. Defendant also sought summary judgment dismissing the sixth through eighth causes of action on the ground of lack of medical necessity. By order entered May 16, 2014, insofar as is relevant to this appeal, the Civil Court denied the branches of plaintiff’s motion seeking summary judgment upon the first, second and fifth causes of action and granted the branches of defendant’s cross motion seeking summary judgment dismissing the first, second, and fifth through eighth causes of action.

In support of the branches of its cross motion seeking summary judgment dismissing the sixth through eighth causes of action, defendant submitted a sworn peer review report which set forth a factual basis and medical rationale for the peer reviewer’s determination that there was a lack of medical necessity for the services at issue. In opposition to those branches of defendant’s cross motion, plaintiff submitted an affidavit from a doctor which failed to meaningfully refer to, let alone sufficiently rebut, the conclusions set forth in the peer review report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App [*2]Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]).

Contrary to plaintiff’s contention, the affidavit executed by defendant’s expert professional coder, submitted in support of the branches of defendant’s cross motion seeking summary judgment dismissing the first, second and fifth causes of action, established that defendant had properly used the workers’ compensation fee schedule to determine the amount which plaintiff was entitled to receive for the services at issue in these causes of action (see e.g. Sama Physical Therapy, P.C. v American Tr. Ins. Co., 53 Misc 3d 129[A], 2016 NY Slip Op 51359[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]).

Accordingly, the order, insofar as appealed from, is affirmed.

PESCE, P.J., ALIOTTA and SOLOMON, JJ., concur.

ENTER:
Paul Kenny
Chief Clerk
Decision Date: July 21, 2017

Legal questions (2)

Questions of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.

Lack of medical necessity

Open the full map

Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?

This decision: Insurer's proof established lack of medical necessity and the provider failed to rebut it

Held the insurer's sworn peer review set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut it, so those causes of action were dismissed.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followed

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Proving a fee schedule defense

Open the full map

Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?

This decision: Insurer proved the billed amount exceeded the applicable fee schedule

Held the insurer's professional coder's affidavit established that it properly used the workers' compensation fee schedule to determine the amounts due, so the claims for the unpaid portions were dismissed.

Excess shownNot established; openDefense rejectedSplit by chargeThis decisionCites it or cited by itCited or followed

Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 147 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Cited in this decision

A label shows how this decision treated the case it cites.

Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) FollowedThe provider's conclusory disagreement with the insurer's supported peer review failed to raise a medical-necessity issue of fact.
Sama Physical Therapy, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51359(U))The insurer established proper recoding of physical therapy services but failed to justify Ground Rule 11 reductions on three claims.

Cited by

A label shows how the later decision treated this one.

New York Med. & Diagnostic Ctr. v GEICO Ins. Co. (2021 NY Slip Op 51138(U)) FollowedThe insurer established untimely submission of five claims but failed to prove its fee-schedule defense to the remaining claim.
Advanced Recovery Equip. & Supplies v Travelers Ins. Co. (2022 NY Slip Op 50690(U)) FollowedThe insurer failed to establish its fee-schedule defense because its analyst's affidavit did not establish expert qualifications.
Heavenly Points Acupuncture v Integon Natl. Ins. Co. (2021 NY Slip Op 50895(U))The insurer established lack of medical necessity, and the provider's conclusory expert affidavit failed to raise a triable issue.
Tandingan PT PC v State Farm Fire & Cas. Co. (2021 NY Slip Op 50869(U))Three provider claims were barred by a declaratory judgment, and the insurer proved fee schedule payment of the fourth.
Pro-Align Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50341(U))The insurer's coding evidence established full payment under the fee schedule for the provider's pain fiber nerve conduction studies.

Similar decisions

Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 50946(U))The insurer proved outstanding verification and proper fee-schedule reductions; a challenge to mailing of payment was unpreserved.
Compas Med., P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51228(U))The insurer failed to establish a timely denial of the fourth claim but proved full fee-schedule payment of the first and fifth claims.
AVM Chiropractic, P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51708(U))The insurer proved full fee schedule payment of three claims but failed to justify Ground Rule reductions of seven others.
A.B. Med. Servs., PLLC v American Tr. Ins. Co. (2007 NY Slip Op 50680(U))Peer reviews citing insufficient information do not raise a medical-necessity issue without proof that the insurer sought verification.
Healthplus Surgery Ctr., LLC v American Tr. Ins. Co. (2022 NY Slip Op 02252)The insurer proved fee-schedule overbilling but failed to support its medical-necessity defense with a factual basis and medical rationale.