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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. MISSING
Regular Panel Decision

Yklik Medical Supply, Inc. v. Allstate Insurance

Plaintiff Yklik Medical Supply, Inc., a medical supply provider, sued Allstate Insurance Company to recover $317 in unpaid medical bills for equipment supplied to its assignor, Tammy Agosto. Yklik moved for summary judgment, asserting proper bill submission and Allstate's failure to timely pay or deny the claim. Allstate argued that the charges exceeded the Workers' Compensation fee schedule and that a partial payment had been made. The court found that Yklik established a prima facie case. The central issue was whether Allstate's fee schedule defense was precluded due to its failure to issue a timely denial within 30 days as mandated by Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The court ruled that since Allstate waited 56 days to send its denial, it was precluded from raising the fee schedule defense, and therefore, summary judgment was granted to the plaintiff.

No-fault insurancesummary judgmenttimely denialfee schedulepreclusion ruleinsurance lawmedical supplybilling practicespersonal injury protectionassignor
References
19
Case No. MISSING
Regular Panel Decision

Pavlova v. Allstate Insurance

The case involves a medical provider (plaintiff) seeking assigned first-party no-fault benefits from an insurer (defendant) for services rendered to Cosby Reavis, utilizing specific medical fee schedule codes. The defendant denied the claim, citing lack of medical necessity and improper billing, particularly for a "By Report" code. The court granted the plaintiff's motion for summary judgment regarding services billed under codes 99215 and 20553, determining the defendant's denial was untimely, thus precluding the defense of medical necessity. However, for code 20999, designated "By Report," the court found the plaintiff failed to provide the necessary supporting documentation as mandated by the Official New York Workers’ Compensation Medical Fee Schedule, thereby failing to establish its prima facie case. Consequently, the defendant's motion for summary judgment was granted for services related to code 20999, leading to the dismissal of that portion of the plaintiff's claim.

Summary JudgmentNo-Fault BenefitsMedical Fee SchedulePrima Facie CaseMedical NecessityTimely DenialBy Report (BR) CodesWorkers' Compensation Medical Fee ScheduleNew York RegulationsIndependent Medical Examination (IME)
References
3
Case No. MISSING
Regular Panel Decision
Mar 09, 2001

Convenient Medical Care, P.C. v. Medical Business Associates, Inc.

Plaintiff, a professional medical corporation, entered into a billing services contract with defendant, a medical billing service provider, in early 1997. The agreement was terminated by plaintiff in 1998 due to alleged failures by the defendant in timely billing worker's compensation patients and delays in returning billing records. Defendant subsequently moved for summary judgment on its counterclaims for breach of contract and an account stated, which the Supreme Court denied. On appeal, the appellate court modified the lower court's order, reversing the denial of summary judgment for defendant's breach of contract counterclaim and granting summary judgment to the defendant on the issue of liability. The court found plaintiff's arguments and evidence insufficient to defeat the defendant's prima facie showing for summary judgment, but denied summary judgment for an account stated due to discrepancies in claimed amounts.

Breach of ContractSummary JudgmentMedical Billing ServicesNegligenceCounterclaimsAppellate ReviewContract TerminationWorker's Compensation PatientsEvidentiary ProofMerger Clause
References
10
Case No. MISSING
Regular Panel Decision
Oct 14, 2008

Westchester Medical Center v. Lincoln General Insurance

The plaintiff appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment to recover no-fault medical benefits. The appellate court reversed the order, granting the plaintiff's motion. The plaintiff successfully demonstrated a prima facie case by showing that statutory billing forms were mailed and received, and the defendant failed to either pay or deny the claim within the 30-day period. The court rejected the defendant's arguments that letters advising of an investigation tolled the statutory period and that the period was tolled pending a no-fault application. Additionally, defenses related to Workers' Compensation benefits or the assignor's failure to appear at an examination under oath were found insufficient to defeat the medical provider's right to benefits.

no-fault insurancemedical benefitssummary judgmentinsurance contractstatutory periodtimely denialworkers' compensationpolicy conditionpreclusion remedyappellate review
References
19
Case No. 46885/05, 47943/05, 47945/05
Regular Panel Decision

Robert Physical Therapy, P.C. v. State Farm Mutual Automobile Insurance

This case involves three consolidated claims for first-party no-fault benefits related to physical therapy services. The plaintiff's assignors received physical therapy, and the defendant, an insurer, denied some claims due to disputes over billing codes. The central legal issues concerned whether a physical therapist could utilize billing codes from the medicine fee schedule when such services were not explicitly in the physical medicine schedule, and if range of motion and muscle testing could be billed separately from evaluation and management on the same day. The court determined that physical therapists are not confined to the physical medicine section and can use codes from any section of the medical fee schedule. Furthermore, the defendant failed to provide sufficient evidence to justify its denials regarding separate billing for range of motion and muscle testing. Consequently, the court ruled in favor of the plaintiff, awarding judgment for all disputed amounts.

Physical Therapy BillingNo-Fault BenefitsMedical Fee ScheduleCPT CodesWorkers' Compensation RegulationsEvaluation and Management ServicesRange of Motion TestingMuscle TestingProvider SpecialtyBilling Disputes
References
4
Case No. 07-CV-6149L
Regular Panel Decision
Feb 18, 2010

Johnson v. THE UNIVERSITY OF ROCHESTER MEDICAL CENTER

Plaintiffs Keith Johnson, M.D., and Laura Schmidt, R.N., filed a qui tam action under the False Claims Act against the University of Rochester Medical Center and Strong Memorial Hospital. They alleged defendants defrauded the government by submitting false claims for anesthesiology services under Medicare/Medicaid, claiming physician supervision when it was absent. Johnson also alleged retaliatory discharge for reporting violations, and Schmidt claimed retaliation for refusing to alter medical records. The defendants moved to dismiss, arguing failure to plead fraud with particularity under Fed. R. Civ. P. 9(b) and failure to state a claim under Rule 12(b)(6). Johnson cross-moved to amend the complaint to add claims of libel per se and prima facie tort against Dr. Lustik. The court granted the defendants' motion to dismiss, finding that the plaintiffs failed to allege that any fraudulent bills were actually presented to Medicare/Medicaid. The retaliation claims were also dismissed because the complaints were not made in furtherance of a qui tam action. Johnson's motion to amend was denied as frivolous and in bad faith. Defendants' request for sanctions was denied without prejudice.

False Claims ActQui TamMedicare FraudMedicaid FraudRetaliatory DischargePleading StandardsRule 9(b)Motion to DismissLeave to AmendLibel
References
28
Case No. MISSING
Regular Panel Decision
Jun 30, 2010

John Giugliano, DC, P.C. v. Merchants Mutual Insurance

Plaintiff John Giugliano, DC, EC., as assignee of Laura Hebenstreit, initiated this action to recover first party no-fault benefits from defendant Merchants Mutual Ins. Co. The core dispute, following a trial on June 30, 2010, centered on the plaintiff's billing practices under the New York Workers' Compensation Medical Fee Schedule, specifically regarding the use of surgical CPT codes for chiropractic procedures. Defendant argued against the use of surgical codes and duplicate billing for a specific CPT code, while plaintiff maintained these practices were justified because the procedures were not listed under the chiropractic fee schedule and involved distinct treatment areas. The court ultimately ruled in favor of the plaintiff, concluding that the procedures were properly billed according to the Fee Schedule, thereby entitling the plaintiff to reimbursement.

No-Fault BenefitsChiropractic BillingWorkers' Compensation Fee ScheduleCPT CodesSurgical ProceduresCo-Surgeon BillingInsurance ReimbursementMedical Fee Schedule DisputesSpinal ManipulationMandibular Fracture
References
2
Case No. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
0
Case No. ADJ3496351 (SAC 0319422)
Regular
Sep 27, 2010

SANDRA L. BOYD vs. COUNTY OF SACRAMENTO

This case concerns whether lien claimant MBM Boutique Acupuncture could bill for multiple units of electro-acupuncture (CPT code 97801) per session. The defendant, County of Sacramento, argued that under the Official Medical Fee Schedule (OMFS), 97801 is an untimed code billable only once per session. The Appeals Board reversed the WCJ's decision, finding the defendant's expert bill reviewer's unrebutted testimony established 97801 as an untimed code, limiting reimbursement to one unit per session. Therefore, the defendant's payment was deemed reasonable and consistent with the OMFS, and the lien claimant was awarded nothing further.

Official Medical Fee ScheduleOMFS97801timed proceduresuntimed proceduresdeputy sheriffacupuncturereimbursementbill reviewerunit per session
References
2
Case No. MISSING
Regular Panel Decision
May 12, 1998

Conway v. Beth Israel Medical Center

Timothy Conway, a construction worker, was injured while stepping on an A-Frame dolly in a storage room owned by Beth Israel Medical Center, causing him to fall. He appealed an order from the Supreme Court, Rockland County, which granted Beth Israel's motion for summary judgment dismissing the complaint. The appellate court affirmed the dismissal of the Labor Law § 200 claim due to insufficient evidence of Beth Israel's direction or control over Conway's work and because the danger was readily apparent. The Labor Law § 240 claim was also dismissed as the injury did not involve an elevation-related risk. Finally, the Labor Law § 241 (6) claim was dismissed because the Industrial Code provisions relied upon (12 NYCRR 23-1.7 [e] [1] and [2]) were not applicable, as the storeroom was not a "passageway" or "working area" and the dolly was not a "scattered tool".

Personal injuryConstruction accidentLabor LawSummary judgmentWorkplace safetyA-Frame dollyElevation riskIndustrial Code violationRockland County Supreme CourtAppellate Division
References
13
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