Power Acupuncture P.C. v State Farm Mut. Auto. Ins. Co.
Annotate this CaseDecided on March 20, 2006
Civil Court of the City of New York, Kings County
Power Acupuncture P.C., Plaintiff,
against
State Farm Mutual Automobile Ins. Co., Defendant.
106648 / 04
Jack M. Battaglia, J.
Plaintiff appeared by Gary Tsirelman, Esq, Greg Lansky, Esq., and Massimiliano Valerio, Esq. of Gary Tsirelman, P.C.; Defendant appeared by Robert B. Brown, Esq. and Samuel K. Rubin, Esq. of Picciano and Scahill, P.C.
A licensed acupuncturist is entitled to recover assigned first-party no-fault benefits based upon the "prevailing fee [for licensed services] in the geographic location of the provider subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established" by the Superintendent of Insurance. (See 11 NYCRR §68.5[b].) The provider bears the burden of coming forward with evidence of the "prevailing fee" in its geographic location, while the insurer has the burden of coming forward with evidence that the provider's fee is not "consisten[t] with charges permissible for similar procedures."
Power Acupuncture, PC is seeking to recover from State Farm Mutual Automobile Insurance Company the total unpaid balance on six bills submitted to the insurer, which amount the parties have stipulated to be $800.24. Each of the bills describes the service rendered as "acupuncture", and seeks compensation at the rate of $100.00 for each treatment session. The insurer paid on each bill at the rate of $42.84 per session, staing that "[t]his base fee was calculated according to the New York Workers' Compensation Board Schedule of Medical Fees. (New York Workers' Compensation Board Schedule of Medical Fees, Page 9.)"
At a trial, of sorts, held on September 16 and September 28, 2005, each party presented one witness. Power Acupuncture offered the testimony of Elyse Josephs, a licensed acupuncturist, who described generally the theory and practice of acupuncture, the training and licensing requirements for acupuncturists, and the certification requirements for physicians and chiropractors who render acupuncture services. (See, generally, Education Law §§8211, 8216[3].) State Farm offered the testimony of Donna Frederick, one of its claims representatives, who described the insurer's practice of paying for acupuncture services rendered by licensed acupuncturists at the rate provided in the Workers' Compensation Board fee schedule for [*2]acupuncture services rendered by a physician.
The parties recognized at trial that the resolution of their dispute depended essentially on an interpretation and application of the No-Fault Law (see Insurance Law §5102 et seq.) and the Superintendent of Insurance's implementing regulations. Specifically, the issue is whether a licensed acupuncturist is entitled to be paid based upon the "prevailing fee" charged by acupuncturists for licensed services, or based upon the fee provided for payment of acupuncture services rendered by a physician. The parties agreed to submit briefs arguing their respective views of the law and regulations. They also agreed, for this case only, that, if the Court determined that Power Acupuncture is entitled to be paid based upon the "prevailing fee", the fee shall be deemed to be $100.00 per session. This Court has since held in another case that the provider bears the burden of coming forward with evidence as to the "prevailing fee". (See AVA Acupuncture P.C. v Elco Administrative Services Co., 10 Misc 3d 1079[A], 2006 NY Slip Op 50158[U], *6-*8 [Civ Ct, Kings County].)
Section 5102(a)(1) of the No-Fault Law defines "basic economic loss" as including "[a]ll necessary expenses incurred for...professional health services", "subject to the limitations of" §5108 of the Law. (See Insurance Law §5102[a][1].) Section 5108 provides that the Superintendent of Insurance "shall promulgate rules and regulations implementing and coordinating the provisions of" the No-Fault Law and the Workers' Compensation Law "with respect to charges for the professional health services specified in" §5102(a)(2), "including the establishment of schedules for all such services for which schedules have not been prepared and established by the chairman of the workers' compensation board." (See Insurance Law §5108[b].) But the "charges for services specified in" §5102(a)(1) "shall not exceed the charges permissible under the schedules prepared and established by the chairman of the workers' compensation board." (See Insurance Law 5108[a].)
Under the statute, therefore, if a charge for a covered "professional health service" is found in a Workers' Compensation schedule, that is the permissible charge under the No-Fault Law; but, if there is no charge for the service found in a Workers' Compensation schedule, the charge is to be determined by the regulations of the of the Superintendent of Insurance. Some uncertainty arises, however, because the No-Fault Law speaks in terms of covered services, whereas the Workers' Compensation schedules establish fees according to the licensed status of the provider. As will appear, acupuncture services rendered by a certified physician are compensated at a different fee under the Workers' Compensation schedules than acupuncture services rendered by a certified chiropractor, and, most importantly for present purposes, there is no coverage under the Workers' Compensation schedules for acupuncture services rendered by a licensed acupuncturist.
The Superintendent's no-fault regulations are not entirely successful in dissipating any uncertainty, as this action illustrates. They provide, in the first instance, that "[c]harges for [professional health] services shall be covered pursuant to schedules promulgated under section 5108 of the Insurance Law and Part 68 of this Title (Regulation 83)." (See 11 NYCRR §65-[*3]3.16[a][6].) In Part 68, the Superintendent adopts the "existing fee schedules prepared and established by the chairman of the Workers' Compensation Board", and, "[i]f a fee schedule has been adopted for a licensed health care provider, the fee for services provided shall be the fee adopted or established for that licensed health care provider." (See 11 NYCRR §68.1[a], [b][2].) A "licensed healthcare provider" is defined as a "licensed healthcare professional acting within the scope of his or her license or an entity properly formed in accordance with applicable law and acting within the scope of its license." (11 NYCRR §68.1[b][3].)
When acupuncture services are rendered by a certified physician or chiropractor, the determination of the permissible charge is relatively clear. There is a Workers' Compensation Medical Fee Schedule and a Workers' Compensation Chiropractic Fee Schedule (as well as schedules for podiatry and psychology.) The respective fee schedules provide a "unit value" or "relative value" for described services and a "conversion factor" for each of four geographic regions. The permissible charge is determined by multiplying the relative value for the service by the conversion factor, which is a monetary amount identified by the zip code of the provider. Both the Medical Fee Schedule and the Chiropractic Fee Schedule describe four acupuncture services, two with electrical stimulation and two without, two for the initial 15 minute "one-on-one contact with the patient" and two for additional 15 minutes of contact. The relative values are the same for each of the services in both the Medical Fee Schedule and the Chiropractic Fee Schedule.
A physician, however, will be entitled to a higher fee for each of the described services, because the conversion factors for physicians range from $6.49 to $8.45 across the four regions, whereas those for chiropractors range from $4.44 to $5.78. For example, when the relative value for an initial 15 minute contact for acupuncture without electrical stimulation rendered by a physician, i.e. 3.55, is multiplied by the conversion factor for physicians in Region IV (where Power Acupuncture is located), i.e. $8.45, the permissible charge is $30.00, whereas when the same relative value is multiplied by the conversion factor for chiropractors in Region IV, i.e. $5.78, the permissible charge is $20.52. The difference presumably reflects the relative market values for the services in various geographic areas.
But what about acupuncture services rendered by a licensed acupuncturist, for whom there is no "dedicated" Workers' Compensation fee schedule. In a section of the regulations titled "[e]stablishment of certain health provider schedules", the Superintendent of Insurance "establishes fee schedules for professional health services referred to in" §5102(a)(1) "for which schedules have not been prepared and established by the chairman of the Workers' Compensation Board." (11 NYCRR §68.2[a].) Those schedules are to be found in Appendix 17-C. (See id.) In Appendix 17-C, the Superintendent establishes fee schedules for various dental, social work, therapy, optometric, and thermographic services, but not for any acupuncture services.
In a section titled "[h]ealth services not set forth in schedules", the Superintendent prescribes the method for determining the permissible charge for such services, first for when the Superintendent "has adopted or established a fee schedule applicable to the provider" (see 11 [*4]NYCRR §68.5[a]), and then for when the Superintendent has not done so (see 11 NYCRR §68.5[b]). For our purposes, the Superintendent has not "adopted" a fee schedule applicable to licensed acupuncturists, since none has been established by the chairman of the Workers' Compensation Board, and the Superintendent has not as yet "established" a fee schedule applicable to licensed acupuncturists, as was done in Appendix 17-C for other providers that were not covered by a Workers' Compensation Fee Schedule.
In such circumstances "the permissible charge for such service shall be the prevailing fee in the geographic area of the provider subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the superintendent." (11 NYCRR §68.5[b].) Indeed, in two opinions, dated, respectively, January 5, 2004 and October 6, 2004, the Office of General Counsel of the New York State Insurance Department reaches the same conclusion. (See also Great Wall Acupuncture, P.C. v Geico General Ins. Co., 8 Misc 3d 1019(A), 2005 NY Slip Op 51199[U], *2 [Civ Ct, Kings County].)
State Farm argues nonetheless that the statute and regulations "are clear that where there is a scheduled service (acupuncture) but an unscheduled provider (licensed acupuncturist) the provider is limited to the fee identified for the scheduled service absent a showing of unusual procedures or unique circumstances." (See Defendant's Trial Memorandum of Law, at 7.) In doing so, State Farm characterizes the Insurance Department's opinions as "erroneously perpetuat[ing] a mistake and application of [its own] regulation." (See id., at 14-15.) In this latter regard, State Farm's position is clearly and seriously at variance with the mandate that we give deference to the opinions of the Superintendent. (See Medical Society of State v Serio, 100 NY2d 854, 863-64 [2003].)
On its own merits, moreover, State Farm's argument ignores the reasonably clear fabric of the Superintendent's regulations, as well as its own failure, if not inability, to explain why, assuming its position were correct, the licensed acupuncturist should be compensated according to the conversion factor for a physician rather than for a chiropractor. The proposition is not self-evident, either logically or legally, and there was no evidence at trial to support it.
It is true, no doubt, that, even under the applicable regulation, the insurer may "review" the acupuncturist's charges "for consistency with charges permissible for similar procedures already adopted or established by the superintendent." (See 11 NYCRR §68.5[b].) For a number of reasons, however, that qualification to payment on a "prevailing fee" basis cannot help State Farm here. First, that is not the basis on which Power Acupuncture's charges were reduced, as stated in State Farm's denials. It is clear from the denials that the "fee was calculated according to the...Schedule for Medical Fees", and, as has been demonstrated, that was wrong. More importantly, neither in the denials nor at trial was there any showing that, even ignoring the identity and status of the practitioner, the acupuncture services that were rendered were "similar" to the services described in the fee schedule and associated with the particular relative value used in the calculation. [*5]
State Farm contends that "the claimant would have the burden to show that the reduction is not consistent with the fees for such scheduled services." The contention is inconsistent with both the structure and clear meaning of the governing regulation, which states that the permissible charge "shall be the prevailing fee", only "subject to review by the insurer." (See 11 NYCRR §68.5[b].) Whatever effect might be given the results of the insurer's "review", the insurer that denies or reduces payment based upon such a review must bear the burden of, at least, coming forward with evidence that the provider's fee is not "consisten[t] with charges permissible for similar procedures." (See id.)
To the extent that State Farm is contending that, generally, the fee for a service described in any fee schedule can never be higher than the maximum fee that would be permissible for any provider for whom there is such a schedule, or that, specifically, a licensed acupuncturist is never permitted a fee for any service described in the physician's fee schedule that is higher than the fee permitted for the physician, those contentions are not supported by either the statute or current regulations. The statute provides only that, when there is an applicable Workers' Compensation fee schedule, the fee for no-fault benefits may not exceed the amount determined by that schedule, "except where the insurer or arbitrator determines that unusual procedures or unique circumstances justify the excess charge" (see Insurance Law §5108[a]); and, when there is no such applicable fee schedule, the Superintendent need only "consult[]" and "coordinat[e]" with the chairman of the Workers' Compensation Board in establishing an appropriate fee (see Insurance Law §5108[b]). Although the Superintendent may well have the authority to promulgate regulations that would provide as State Farm contends, that authority has not been exercised.
Specifically, the statute that authorizes a certification program for physicians and others who are not licensed acupuncturists, is subject to the proviso that "such certified acupuncturists do not represent themselves as licensed acupuncturists." (See Education Law §8216[3].) The statute clearly reflects at least an assumption that the acupuncture services rendered by a certified physician and those rendered by a licensed acupuncturist are not the same. On this record, that statutory assumption is enough to require rejection of State Farm's practice of automatically reducing bills submitted by licensed acupuncturists to the fees permissible for certified physicians.
Given the conclusions required by this record to resolve this case, it is both unnecessary and inappropriate for the Court to address Power Acupuncture's other arguments concerning, what it calls, the "Review Clause", including the questions raised concerning its constitutionality and its meaning and application. (See Post-Trial Memorandum, at 15-32.) The Court notes, moreover, that, although it may have the jurisdiction to pass on most, if not all, of those questions in the context of an action seeking payment of one or more bills, such an action does not appear to this Court to be the most appropriate vehicle for a full exploration and considered resolution of those questions. [*6]
It appears to this Court that those healthcare providers and insurers regularly participating in no-fault first-party benefits litigation have chosen litigation strategies that involve litigating and relitigating the same issues in hundreds, if not thousands, of actions before different Civil Court and District Court judges, crowding out the types of actions the limited-jurisdiction courts were designed to resolve. The Court recognizes and appreciates that, in this action, the parties took a somewhat different tack, and have clearly expended significant effort to brief a wide range of questions that are raised by the statute and regulations as they apply to the services rendered by licensed acupuncturists. It seems true, nonetheless, that a broader-scoped proceeding in Supreme Court one in which a number of providers and insurers might participate would be a more appropriate forum for resolution of the constitutional and other questions raised by this, and other, no-fault actions.
The Court has noted Plaintiff's counsel's request for an attorney fee in excess of the limitations generally applied to no-fault disputes. (See 11 NYCRR §65-4.6.) And, again, the Court recognizes the effort made by counsel for both parties. But this case has not been resolved on the issues that attracted much of Plaintiff's counsel's attention. In the world of no-fault, moreover, where the parties do not want for creativity in raising new questions for the courts to resolve, there is a real risk that the exception to the limitations will render the rule meaningless.
Judgment is awarded to Plaintiff for $800.24, with statutory interest and attorney fees, plus costs.
March 20, 2006__________________________
Judge, Civil Court
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