ARBITRATION AWARD. Injured Person(s) hereinafter referred to as: injured person-assignor

Transcription

1 American Arbitration Association New York No-Fault Arbitration Tribunal In the Matter of the Arbitration between: Domny Medical Services, PC (Applicant) - and - State Farm Fire and Casualty Company (Respondent) AAA Case No Applicant's File No Insurer's Claim File No F-647 NAIC No ARBITRATION AWARD I, Tracy Morgan, the undersigned arbitrator, designated by the American Arbitration Association pursuant to the Rules for New York State No-Fault Arbitration, adopted pursuant to regulations promulgated by the Superintendent of Insurance, having been duly sworn, and having heard the proofs and allegations of the parties make the following AWARD: Injured Person(s) hereinafter referred to as: injured person-assignor Hearing(s) held on 09/15/2017 Declared closed by the arbitrator on 09/15/2017 Mark Yosef, Esq. from Korsunskiy Legal Group P.C. participated in person for the Applicant Jerry Maline, Esq. from Richard T. Lau & Associates participated in person for the Respondent The amount claimed in the Arbitration Request, $ 2,039.24, was NOT AMENDED at the oral hearing. Stipulations WERE NOT made by the parties regarding the issues to be determined. Summary of Issues in Dispute The Applicant is the assignee of no-fault benefits from injured person-assignor (BH), a 59 year old male who was involved in a motor vehicle accident on May 13, Following the accident, the injured person-assignor sought medical treatment and underwent cervical and lumbar plexus pain fiber NCS tests performed by Applicant on June 7, 2016 billed under CPT code Respondent partially paid and denied the remainder of Applicant's claim for reimbursement contending that Applicant billed in excess of the New York State Workers' Compensation Fee Schedule. The issue presented on this arbitration is whether the services in dispute were properly billed under the New York State Workers' Compensation Fee Schedule? Page 1/5

2 4. Findings, Conclusions, and Basis Therefor This hearing was conducted using documents contained in ADR Center. Any documents contained in the folder are hereby incorporated into this hearing. I have reviewed the relevant exhibits contained in the electronic file maintained by the American Arbitration Association and have considered all of the stipulations and arguments presented by both parties at the hearing of this matter. No witnesses appeared or testified. A health care provider establishes its prima facie entitlement to no-fault benefits by submitting evidentiary proof that the prescribed statutory billing forms were mailed to and received by the insurer and that payment of no-fault benefits are overdue See Insurance Law 5106 [a]; 11 NYCRR [g]; Viviane Etienne Medical Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 (2015). I find that Applicant established its prima facie entitlement to first person no-fault benefits as proof of claim was mailed to and received by the insurer and payment of No-Fault benefits are overdue. Pursuant to both the Insurance Law and the Regulations promulgated by the Superintendent of Insurance, an insurer must either pay or deny a claim for no-fault benefits within 30 days from the date an applicant supplies proof of claim See, Insurance Law 5106[a]; 11 NYCRR 65.15[g]; Presbyterian Hosp.in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 278 (1997). Here, Respondent partially paid $ for each bill and timely denied the remaining balances contending that Applicant billed the services improperly and exceeded the New York State Workers' Compensation Fee Schedule. Applicant billed for the disputed services pursuant to code CPT Code is assigned to "Unlisted neurological or neuromuscular diagnostic procedure" in the Workers' Compensation Medical Fee Schedule and is a By Report code. A "By Report" item is an item for which no relative value is established pursuant to the fee schedule. Ground Rule 2 to Chapter 1 (Introduction and General Guidelines) of the Workers' Compensation Chiropractic Fee Schedule sets forth reporting requirements for services billed with CPT codes which are "By Report." Among the requirements is that "the nature, extent, and need for the procedure or service, the time, the skill, and equipment necessary, etc., is to be furnished." Also, the health service provider must establish a unit value consistent in relativity with other unit values in the fee schedule. Page 2/5

3 Applicant argued that is the appropriate code for the disputed testing. While the testing report was submitted on this Record it does not establish a unit value consistent in relativity with other unit values in the fee schedule, as required by the aforesaid Ground Rule. To support its fee schedule defense, Respondent submitted an Affidavit from a certified professional coder Mercy Acuna who is employed by Signet Claim Solutions. Ms. Acuna states the correct reimbursement for the pf-ncs is $ for the upper extremities and $ for the lower extremities. Ms. Acuna arrived at her calculation utilizing CPT Code 0110T - Quantitative sensory testing as it most closely resembles the services performed. The relative value is based on extremity and not the number of nerves. Code was utilized to determine reimbursement. Using the chiropractic conversion factor, 5.78 x relative value = x 2 extremities = $ Applicant did not submit a fee audit or affidavit to refute Respondent's contentions. After a review of the evidence in this Record and consideration of the arguments presented, I find that Respondent's proof as to the proper fee for the testing in dispute is sufficiently detailed and provides a medical rationale for the fee reductions. I am persuaded by Ms. Acuna's conclusion that the CPT Assistant recommends that Category III codes be used for reimbursement of the service. Category III codes are temporary codes identifying emerging technology "to evaluate the clinical efficacy and outcomes and collect unbiased data" See, Bronx Chiropractic Services, PC and Geico Insurance Company, AAA Case Number (Arbitrator Charles Sloane, 8/20/12). Category III codes 01016T T offer valid options for reporting the PF-NCS. The Category III codes for QST (CPT 0106T T) are "by report" and more appropriately reflect the nature of the services rendered. Applicant argued that the QST is a different test than the pf- NCS. I find that for billing purposes, the Category III Codes (which permit billing per extremity as opposed to per nerve) offer a more consistent standard for reasonable compensation. I also find persuasive the reasoning of fellow arbitrators Feilich (AAA# ), Wolf (AAA# ), Esposito (AAA# ), Peters (AAA# ), Melis (AAA# ), Horowitz (AAA# ), Haskel (AAA# ), and Rosenberger (AAA# ). In accordance with the Category III codes, billing is appropriately submitted for one unit of service for each extremity rather than each site tested and therefore, I find that Applicant is entitled to $72.83 for each extremity tested. Since Respondent already paid $ for each test, Applicant is owed no further reimbursement. Applicant's claim is denied. 5. Optional imposition of administrative costs on Applicant. Applicable for arbitration requests filed on and after March 1, I do NOT impose the administrative costs of arbitration to the applicant, in the amount established for the current calendar year by the Designated Organization. Page 3/5

4 6. I find as follows with regard to the policy issues before me: The policy was not in force on the date of the accident The applicant was excluded under policy conditions or exclusions The applicant violated policy conditions, resulting in exclusion from coverage The applicant was not an "eligible injured person" The conditions for MVAIC eligibility were not met The injured person was not a "qualified person" (under the MVAIC) The applicant's injuries didn't arise out of the "use or operation" of a motor vehicle The respondent is not subject to the jurisdiction of the New York No-Fault arbitration forum Accordingly, the claim is DENIED in its entirety This award is in full settlement of all no-fault benefit claims submitted to this arbitrator. State of New York SS : County of Nassau I, Tracy Morgan, do hereby affirm upon my oath as arbitrator that I am the individual described in and who executed this instrument, which is my award. 10/05/2017 (Dated) Tracy Morgan IMPORTANT NOTICE This award is payable within 30 calendar days of the date of transmittal of award to parties. This award is final and binding unless modified or vacated by a master arbitrator. Insurance Department Regulation No. 68 (11 NYCRR ) contains time limits and grounds upon which this award may be appealed to a master arbitrator. An appeal to a master arbitrator must be made within 21 days after the mailing of this award. All insurers have copies of the regulation. Applicants may obtain a copy from the Insurance Department. Page 4/5

5 ELECTRONIC SIGNATURE Document Name: Final Award Form Unique Modria Document ID: b ffe7a4ee6e7f457857d338e7 Electronically Signed Your name: Tracy Morgan Signed on: 10/05/2017 Page 5/5