May 18, 2015

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U))

https://www.beynensonlaw.com/case-law/alleviation-med-servs-p-c-v-state-farm-mut-auto-ins-co-2015-ny-slipop-50778u/

Court: Appellate Term, Second Department
Decided: May 18, 2015
Citation: 2015 NY Slip Op 50778(U) · 47 Misc 3d 149(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Contrasted (cf., but see) in 1 later decision (see Cited by)
Issues: Fee schedule
Legal questions: Proving a fee schedule defense (see the maps)

Cite as

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 47 Misc 3d 149(A), 2015 NY Slip Op 50778(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015)

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 established that the workers' compensation fee schedule supported reducing the billed reimbursement using CPT code 20552. The provider challenged reduction of a $4,000 bill under CPT code 20553 to $645.90. The insurer's affidavit demonstrated proper application of Ground Rules 3 and 5 and use of CPT code 20552 to calculate payment. A potential alternative calculation was irrelevant because it was not used. The denial adequately identified the defense through a checked fee-schedule box and reference to an attached Explanation of Review. The Appellate Term, Second Department, affirmed summary judgment dismissing the complaint for the insurer and denial of the provider's cross motion.

Reported in New York Official Reports at Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U))

[*1]

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co.

2015 NY Slip Op 50778(U) [47 Misc 3d 149(A)]

Decided on May 18, 2015

Appellate Term, Second Department

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

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on May 18, 2015

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-2681 K C

Alleviation Medical Services, P.C. as Assignee of DEXTON ELLIS, Appellant,
against
State Farm Mutual Automobile Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Dawn Jimenez Salta, J.), entered October 12, 2012. The order granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment.

ORDERED that the order is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment.

Plaintiff’s main argument on appeal with respect to defendant’s cross motion is that defendant failed to demonstrate that it had properly reduced the sum billed for CPT code 20553 from $4,000 to $645.90 pursuant to the workers’ compensation fee schedule. Contrary to plaintiff’s contention, the affidavit submitted by defendant was sufficient to demonstrate, prima facie, that Ground Rule 3 and Ground Rule 5 were appropriately applied to the services billed, and that defendant properly applied CPT code 20552 in order to determine the amount due, which it calculated to be $645.90. It is of no relevance to the determination of this appeal that defendant has described a potential alternate calculation which, had defendant used it, would have concluded that only $416.85 was due.

Although plaintiff further argues that defendant’s proffered defense was not set forth in its denial of claim form, a checked box on the form indicated that benefits were denied because the fees were not in accordance with the fee schedule, and the denial referenced an attached “Explanation of Review.”

In view of the foregoing, defendant’s motion for summary judgment dismissing the complaint was properly granted and plaintiff’s cross motion for summary judgment was properly denied.

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.

Decision Date: May 18, 2015

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 the insurer's affidavit showed prima facie that Ground Rules 3 and 5 were properly applied and that recoding CPT 20553 as 20552 properly yielded the reduced amount it paid.

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

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.

Cited by

A label shows how the later decision treated this one.

Renelique v Allstate Ins. Co. (2017 NY Slip Op 51141(U)) Contrasted (cf., but see)The insurer established proper application of the workers' compensation fee schedule to CPT code 20553, and the provider did not rebut its showing.
Allstate Ins. Co. v Buffalo Neurosurgery Group (2019 NY Slip Op 03749)The insurer established a fee-schedule defense but failed to show that the assignor's spinal fusion surgery was medically unnecessary.
Acupuncture Healthcare Plaza I, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50945(U))The insurer failed to prove timely fee-schedule denials or lack of coverage for two claims, but raised a triable coverage issue.

Similar decisions

Alleviation Med. Servs., P.C. v American Tr. Ins. Co. (2015 NY Slip Op 51628(U))The provider failed to establish an overdue claim or a timely denial that was conclusory, vague, or legally meritless.
Alleviation Med. Servs., P.C. v Farmers New Century Ins. Co. (2016 NY Slip Op 50379(U))The insurer's IME nonappearance defense was precluded on the first claim because it failed to deny within 30 days or establish tolling.
Alleviation Med. Servs., P.C. v Geico Ins. Co. (2015 NY Slip Op 50396(U))The provider's unopposed motion failed because its papers did not establish an overdue claim or a timely denial lacking legal merit.
Alleviation Med., P.C. v Allstate Ins. Co. (2015 NY Slip Op 51630(U))The provider's appellate arguments against dismissal for lack of a covered loss were raised for the first time on appeal.
Alleviation Med. Servs., P.C. v 21st Century Ins. Co. (2016 NY Slip Op 51347(U))Conflicting proof of mailing and nonreceipt raised a factual issue as to whether the insurer's time to pay or deny began to run.