November 17, 2009

Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467)

https://www.beynensonlaw.com/case-law/great-wall-acupuncture-p-c-v-geico-ins-co-2009-ny-slip-op-29467/

Court: Appellate Term, Second Department
Decided: November 17, 2009
Citation: 2009 NY Slip Op 29467 · 26 Misc 3d 23
Posture: Trial
Outcome: Insurer prevailed
Later treatment: Limited in 1 and followed in 86 later decisions (see Cited by)
Issues: Fee schedule
Legal questions: Proving a fee schedule defense (see the maps)

Cite as

Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 (App Term, 2d Dept 2009)

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.

An insurer may use the chiropractic acupuncture fee schedule to reimburse acupuncture services performed by a licensed acupuncturist. The insurer partially paid the provider's claim and timely denied the balance as exceeding the applicable maximum fees. At trial, the provider's witness held both acupuncture and chiropractic licenses. Under Education Law §§ 8212, 8214 and 8216 and 8 NYCRR 52.16 (b), acupuncture licensure training remains the same even when the applicant is licensed in another profession. Because reimbursement under the workers' compensation schedule for acupuncture performed by chiropractors was undisputed, no additional payment was due. The Appellate Term, Second Department, affirmed the judgment dismissing the complaint in the insurer's favor.

Reported in New York Official Reports at Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467)

Great Wall Acupuncture, P.C. v Geico Ins. Co.

2009 NY Slip Op 29467 [26 Misc 3d 23]

Accepted for Miscellaneous Reports Publication

AT2

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, February 17, 2010

[*1]

Great Wall Acupuncture, P.C., as Assignee of Maria Gonzalez, Appellant,
v
GEICO Insurance Company, Respondent.

Supreme Court, Appellate Term, Second Department, November 17, 2009

APPEARANCES OF COUNSEL

Law Offices of Eva Gaspari, PLLC, Brooklyn, and Mischel & Horn, P.C., New York City (Scott T. Horn of counsel), for appellant. Law Offices of Teresa M. Spina, Woodbury (Emilio A. Cacace of counsel), for respondent.

{**26 Misc 3d at 24} OPINION OF THE COURT

Memorandum.

Ordered that the judgment is affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant had partially paid plaintiff’s claim prior to the commencement of the action. 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. After a nonjury trial on the issue of the propriety of the fees charged, the Civil Court granted judgment to defendant dismissing the complaint, and this appeal by plaintiff ensued.

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]). Indeed, at trial, plaintiff’s witness, who was both a licensed acupuncturist and a licensed chiropractor, so testified. 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 (see Great Wall Acupuncture v GEICO Gen. Ins. Co., 16 Misc 3d 23 [App Term, 2d & 11th Jud Dists 2007]; see also AVA Acupuncture, P.C. v GEICO Gen. Ins. Co., 23 Misc 3d 140[A], 2009 NY Slip Op 51017[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; AVA Acupuncture, P.C. v GEICO Gen. Ins. Co., 17 Misc 3d 41 [App Term, 2d & 11th Jud Dists 2007]; Ops Gen Counsel NY Ins Dept No. 04-10-03 [Oct. 2004] [http://www.ins.state.ny.us/ogco2004/rg041003.htm (accessed Nov. 25, 2009)]). Consequently, [*2]since it is undisputed that the instant defendant reimbursed{**26 Misc 3d at 25} plaintiff pursuant to the workers’ compensation fee schedule for acupuncture services rendered by a chiropractor, plaintiff is not entitled to any additional reimbursement. Accordingly, the judgment dismissing the complaint is affirmed.

Weston, J.P., Rios and Steinhardt, JJ., concur.

Legal questions

A question 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.

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 as a matter of law, given licensure requirements, that an insurer may pay a licensed acupuncturist at the chiropractor acupuncture rate, and since it undisputedly did so nothing more was due.

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

Of the 284 decisions on this question in the Second Department courts and the Court of Appeals, 146 (this one included) are in the same category. 11 decisions in other departments that cite or are cited by this one are on the full map.

Cited in this decision

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

Great Wall Acupuncture v GEICO Gen. Ins. Co. (2007 NY Slip Op 27164) FollowedThe insurer properly reimbursed the licensed acupuncturist at chiropractor rates because similar services and licensing requirements supported them.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co. (2009 NY Slip Op 51017(U))Acupuncture services rendered by a licensed acupuncturist may be reimbursed at the workers' compensation fee schedule rate for chiropractors.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co. (2007 NY Slip Op 27371)An insurer may use the workers' compensation fee schedule for chiropractors to reimburse acupuncture performed by a licensed acupuncturist.

Cited by (100)

A label shows how the later decision treated this one.

Global Liberty Ins. Co. of N.Y. v Acupuncture Now, P.C. (2019 NY Slip Op 08942) LimitedThe insurers failed to establish that licensed acupuncturists could be reimbursed only under the chiropractic fee schedule.
Akita Med. Acupuncture, P.C. v Clarendon Ins. Co. (2013 NY Slip Op 51860(U)) FollowedThe insurer properly reimbursed a licensed acupuncturist at the workers' compensation fee-schedule rate for chiropractic acupuncture.
Raz Acupuncture, P.C. v AIG Indem. Ins. Co. (2010 NY Slip Op 51177(U)) FollowedAn insurer may use the workers' compensation acupuncture fee schedule for chiropractors to reimburse a licensed acupuncturist.
Natural Therapy Acupuncture, P.C. v Interboro Ins. Co. (2012 NY Slip Op 51350(U)) FollowedThe insurer established deductible and fee schedule defenses to three claims and nonreceipt of the claim underlying the second cause of action.
W.H.O. Acupuncture, P.C. v Progressive Preferred Ins. Co. (2012 NY Slip Op 51335(U)) FollowedThe insurer failed to explain why it reduced some CPT code 97811 claims but denied others entirely for missing time documentation.
GBI Acupuncture, P.C. v 21st Century Ins. Co. (2015 NY Slip Op 51235(U)) FollowedThe insurer established timely denials and proper reimbursement under the workers' compensation fee schedule for the acupuncture services.
Jing Luo Acupuncture, P.C. v NY City Tr. Auth. (2018 NY Slip Op 51083(U)) FollowedA fee schedule defense is not precluded by an untimely denial for services governed by 11 NYCRR 65-3.8 (g).
LVOV Acupuncture, P.C. v Geico Ins. Co. (2011 NY Slip Op 51721(U)) FollowedThe insurer established full fee-schedule payment for acupuncture codes 97810 and 97811 but offered no basis to dismiss the initial-visit claim.
East Coast Acupuncture, P.C. v Hereford Ins. Co. (2016 NY Slip Op 26042) FollowedA fee schedule defense for services rendered after April 1, 2013 is not precluded by a denial issued beyond 30 days.
Z. M. S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51891(U)) FollowedA fee-schedule defense is not subject to preclusion for services rendered after April 1, 2013, under 11 NYCRR 65-3.8 (g).

Show all 100 citing decisions