Barakat P.T., P.C. v Progressive Ins. Co. (2021 NY Slip Op 50342(U))

CV-730032-18/KI

The Rybak Firm, PLLC (Oleg Rybak of counsel), New York City, for Barakat P.T., P.C., plaintiff. Law Offices of Rachel Perry, Lake Success (Edward R. Johannes of counsel), for Progressive Insurance Company, defendant.

BACKGROUND

On April 22, 2017, plaintiff’s assignor, Jerrod Bratcher, was allegedly injured in an automobile accident (see plaintiff’s exhibit 4 in support of motion, complaint ¶ 2).

On April 27, 2017, plaintiff allegedly provided the following services to Bratcher:

(see plaintiff’s exhibit 3 in support of motion, NF-3 form dated 5/16/17). According to Amro S Mohamed, P.T., the sole proprietor of plaintiff, the bill was mailed to the insurance carrier on May 16, 2017 (see plaintiff’s exhibit 2 in support of motion, Mohamed aff ¶¶ 1, 21).

On May 30, 2017, defendant allegedly denied the bill in its entirety. According to the Explanation of Benefits (EOB), the amount allowed was $103.95, based on the Workers’ Compensation fee schedule, and the amount fell within a deductible/copay (see defendant’s exhibit C in support of cross motion, NF-10 form and EOB).

The instant action

On July 13, 2018, plaintiff commenced this action seeking to recover assigned first-party no-fault benefits, with interest plus attorneys’ fees (see plaintiff’s exhibit 4 in support of motion, summons and complaint). On August 1, 2018, defendant allegedly answered the complaint (see defendant’s exhibit A in support of cross motion, answer and affidavit of service).

DISCUSSION

“On a motion for summary judgment, the moving party must make a prima facie showing of entitlement to judgment as a matter of law, tendering sufficient evidence to demonstrate the absence of any material issues of fact. If the moving party produces the required evidence, the burden shifts to the nonmoving party to establish the existence of material issues of fact which require a trial of the action”

(Xiang Fu He v Troon Mgt., Inc., 34 NY3d 167, 175 [2019] [internal citations and quotation marks omitted]).

Defendant generally argues that it is entitled to summary judgment dismissing the complaint because plaintiff billed in excess of the fee schedule, and defendant was reimbursed pursuant to the Workers’ Compensation fee schedule (see affirmation of defendant’s counsel ¶¶ 6-10 ^[FN1] ). Defendant contends that the allowable amount was properly applied to the assignor’s deductible (id. ¶¶ 11-12).

A. Workers’ Compensation Fee Schedule

“Insurance Law § 5108 provides, with some exceptions, that charges for services covered under Insurance Law § 5102 ‘shall not exceed the charges permissible under the schedules prepared and established by the chairman of the workers’ compensation board for industrial accidents'” (Government Empls. Ins. Co. v Avanguard Med. Group, PLLC, 127 AD3d 60, 63 [2d Dept 2015], affd 27 NY3d 22 [2016], quoting Insurance Law § 5108 [a]).

To meet its prima facie burden that it fully paid the claims in accordance with the fee schedule, the defendant must submit an affidavit from a no-fault/litigation examiner or from a professional medical coder/biller (Merrick Med., P.C. v A Cent. Ins. Co., 64 Misc 3d 142[A], 2019 NY Slip Op 51264[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2019]; Renelique v American Tr. Ins. Co., 53 Misc 3d 141[A], 2016 NY Slip Op 51526[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]; Oleg’s Acupuncture, P.C. v Hereford Ins. Co., 58 Misc 3d 151[A], 2018 NY Slip Op 50095[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2018][certified medical coder and biller]; Compas Med., P.C. v American Tr. Ins. Co., 56 Misc 3d 133[A], 2017 NY Slip Op 50946[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017] [professional coder]).

The affidavit must show that defendant properly applied the appropriate relative value units and conversion factor assigned to the CPT code(s) for the services rendered in calculating the amount plaintiff was entitled to be reimbursed (see Renelique, 53 Misc 3d 141[A], 2016 NY Slip Op 51526[U]; Renelique v American Tr. Ins. Co., 57 Misc 3d 145[A], 2017 NY Slip Op [*2]51450[U], [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017] [conversion factor not provided]; see also Adelaida Physical Therapy, P.C. v 21st Century Ins. Co., 58 Misc 3d 135[A], 2017 NY Slip Op 51808[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017] [defendant failed to demonstrate that it had used the correct conversion factor]; Liberty Chiropractic, P.C. v 21st Century Ins. Co., 53 Misc 3d 133[A], 2016 NY Slip Op 51409[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016] [defendant failed to demonstrate correct conversion factor was applied]). Lastly, the applicable portion of the fee schedule must be annexed to defendant’s papers (Megacure Acupuncture, P.C. v Clarendon Natl. Ins. Co., 33 Misc 3d 141[A], 2011 NY Slip Op 52199[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]).

Here, defendant failed to meet its prima facie burden demonstrating that plaintiff billed in excess of the fee schedule. Defendant’s counsel argues that, based on an examination of plaintiff’s bill, plaintiff, a physical therapist, used a conversion factor of 8.45, which is reserved for medical doctors, instead of using the conversion factor for physical therapists (affirmation of defendant’s counsel ¶ 8). Defendant’s counsel asserts that the correct conversion factor for plaintiff is 7.70 (id. ¶ 7). However, defendant did not submit an affidavit from a no-fault/litigation examiner or from a professional medical coder/biller, stating that a physical therapist may only bill for services using the conversion factor for physical therapists, or that a physical therapist may not bill for services using the conversion factor for physical medicine, which is 8.45. Neither did defendant’s counsel cite to any ground rules from the fee schedule nor any statutory or case law authority to support his contention. Defendant therefore failed to demonstrate that it had used the correct conversion factor in calculating the reimbursement rate (Laga v GEICO Ins. Co., 58 Misc 3d 127[A], 2017 NY Slip Op 51713[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017]).

B. Reduction of the claim due to a policy deductible

Although defendant did not demonstrate that the bill was properly reduced in accordance with the Workers’ Compensation fee schedule, defendant also argues that the policy under which no-fault benefits are being claimed had a $200 deductible. Insofar as the amount of the bill was within the deductible amount, the court must reach defendant’s alternative argument that the bill was validly denied due to the policy deductible.

To meet its prima burden that the bill was properly denied due to application of a deductible, defendant must submit affidavits and documents establishing that that the automobile insurance policy in question had a personal injury protection deductible, and that the claim at issue was timely denied due to said deductible (Healthy Way Acupuncture, P.C. v 21st Century Indem. Ins. Co., 54 Misc 3d 142[A], 2017 NY Slip Op 50204[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017]; Innovative Chiropractic, P.C. v Progressive Ins. Co., 26 Misc 3d 135[A], 2010 NY Slip Op 50148[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010]).

1. Policy Deductible

Here, defendant submitted a copy of the policy declarations page, which indicates that the automobile policy that defendant issued to the named insured, Jerrod Bratcher, in effect at the time of the accident, has “Mandatory Personal Injury Protection” up to $50,000 for each person, with a $200 deductible (see defendant’s exhibit E in support of motion, Declarations Page at 2). Plaintiff did not raise any objections to this document (see affirmation of plaintiff’s counsel in further support of motion and in opposition to cross motion ¶¶ 14-52).

[*3] 2. Timely Denial

“[A]n insurer must either pay or deny a claim for motor vehicle no-fault benefits, in whole or in part, within 30 days after an applicant’s proof of claim is received. An insurer can extend the 30-day period within which to pay or deny a claim by making a timely demand for further verification of the claim”

(Infinity Health Prods., Ltd. v Eveready Ins. Co., 67 AD3d 862, 864 [2d Dept 2009] [internal citations omitted]). According to defendant’s counsel, the denial was mailed on May 30, 2017 (see affirmation of defendant’s counsel ¶ 11 [table]).

Generally, “proof that an item was properly mailed gives rise to a rebuttable presumption that the item was received by the addressee” (Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33, 46 [2013], affd 25 NY3d 498 [2015] [internal quotation marks omitted]). A party can establish proof of mailing “through evidence of actual mailing (e.g., an affidavit of mailing or service) or—as relevant here—by proof of a sender’s routine business practice with respect to the creation, addressing, and mailing of documents of that nature” (CIT Bank N.A. v Schiffman, —NY3d&mdash, 2021 NY Slip Op 01933, *3 [2021]; New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547, 547 [2d Dept 2006], quoting Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679, 680 [2d Dept 2001]; accord American Tr. Ins. Co. v Lucas, 111 AD3d 423, 424 [1st Dept 2013]).

“Actual mailing may be established by a proper certificate of mailing or by an affidavit of one with personal knowledge” (J.M. Chiropractic Servs., PLLC v State Farm Mut. Ins. Co., 36 Misc 3d 135[A], 2012 NY Slip Op 51348[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012] [internal citation, emendations and quotation marks omitted]). For proof by office practice, “the office practice must be geared so as to ensure the likelihood that the item is always properly addressed and mailed” (Progressive Cas. Ins. Co. v Metro Psychological Servs., P.C., 139 AD3d 693, 694 [2d Dept 2016], citing Nassau Ins. Co. v Murray, 46 NY2d 828, 830 [1978]; Badio v Liberty Mut. Fire Ins. Co., 12 AD3d 229, 229-30 [1st Dept 2004]).

Here, to establish proof of mailing, defendant submitted an affidavit from Tamu Jordan, a Litigation Representative employed by defendant since June 1999 (see defendant’s exhibit B in support of cross motion, Jordan aff ¶ 1), and copies of the denial of claim form and a mailing report (see defendant’s exhibit C in support of motion), which Jordan established were business records (Jordan aff ¶ 6).

According to Jordan, the claims representative electronically creates the document to be mailed, which includes the mailing address, and places the document into a digital file in a centralized computer for mailing (see Jordan aff ¶ 3 [l]). Once the claims representative creates the documents to be mailed, the centralized computer system generates the document with the mailing address (id. ¶ 3 [n]). Documents are printed from the centralized computer system at mailing facilities located in either Highland Heights, Ohio or Colorado Springs, Colorado (see id. ¶ 3 [l]). Once printed, an automated mail machine inserts the document into a windowed envelope so the mailing address is visible (id. ¶ 3 [n]).

Documents mailed in the same windowed envelope are identified with the same Envelope ID, and the sixth and seventh digit of the Envelop ID indicate the facility from which the documents were mailed (id. ¶ 3 [m]). If the sixth and seventh digits are 00 or 02, the documents were mailed from Highland Heights, Ohio; if the sixth and seventh digits are 01, the documents were mailed from Colorado Springs, Colorado (id. ¶ 3 [m]).

In Highland Heights, Ohio, mail is picked up by a United States Postal Service by 1:00 p.m. and 5:00 p.m. Eastern Standard Time, Monday through Friday; in Colorado Springs, Colorado, the mail is picked up by a United States Postal Service by 1:30 p.m. and 5:30 p.m. Mountain Time, Monday through Friday (id. ¶¶ 3[o]-[p]). As the mail is placed into the custody and control the United States Postal Service, information on a Medical Payments Proof of Mailing Report is contemporaneously captured (id. ¶ 3 [a]). The information cannot be altered once it is captured in defendant’s computer system, and the data on the report is compiled the same date that the documents were mailed (id. ¶ 3 [b]).

For denials, two copies are mailed, along with two EOBs (id. ¶ 3 [g]). The information appearing in the NF-10 form and the EOB regarding the recipient, recipient address, patient, dates of service, and the amount billed is obtained from the bill(s) submitted by plaintiff (id. ¶ 3 [i]).

Here, defendant established prima facie proof of mailing of the denial on May 31, 2017, in accordance with a standard office practice or procedure (Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2d Dept 2001]; Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co., 27 Misc 3d 141[A], 2010 NY Slip Op 50997[U] [App Term, 2d Dept, 2d Dept, 2d, 11th & 13th Jud Dists 2010]). The Medical Payments Proof of Mailing Report indicates that two NF-10s and two EOBs were mailed to plaintiff on May 31, 2017, with Envelope ID CMBPI02Q00566 (see defendant’s exhibit C in support of cross motion). Based on the sixth and seventh digits of the Envelope ID on the mailing report and on Jordan’s affidavit, the denial was therefore mailed from Highland Heights, Ohio.

Plaintiff’s arguments in opposition to proof of mailing are unavailing.

“[T]o rebut the presumption, there must be proof of a material deviation from an aspect of the office procedure that would call into doubt whether the notice was properly mailed, impacting the likelihood of delivery to the intended recipient. Put another way, the crux of the inquiry is whether the evidence of a defect casts doubt on the reliability of a key aspect of the process such that the inference that the notice was properly prepared and mailed is significantly undermined. Minor deviations of little consequence are insufficient”

(CIT Bank N.A. v Schiffman, —NY3d—, 2021 NY Slip Op 01933, *3 [2021]). Contrary to plaintiff’s argument, the affidavit stated Jordan’s current title as Litigation Representative (Jordan aff ¶ 1). Additionally, Jordan established personal knowledge of the standard mailing procedures in both Ohio and Colorado, based on training that Jordan received from the facilities at both Ohio and Colorado (id. ¶ 2).

Acupuncture Prima Care, P.C. v State Farm Mutual Auto Ins. Co. (17 Misc 3d 1135[A], 2007 NY Slip Op 52273[U] [Dist Ct, Nassau County 2007]), which plaintiff cites, is distinguishable.

There, to establish proof of mailing, the defendant submitted two affidavits—an affidavit from a claims representative from the defendant’s office in Ballston Spa, New York and an affidavit from a claims support supervisor from the defendant’s office in Melville New York. The claims representative described the procedure for generating the denial of claim forms, which were then sent to Claims Support Services personnel for processing (id. at *2). The affidavit from the Claims Support Services Supervisor stated, in essence, that the generated denial of claim forms are retrieved from a printer, placed in an envelope, and picked up by a courier who delivers the envelope to the United States Postal Service (id. at *2-3).

The court in Acupuncture Prima Care, P.C. ruled, “while this may describe a ‘standard office practice and procedure,’ it does not describe one “used to ensure that items were properly addressed and mailed” (id. at *3 [internal citation omitted]). The court reasoned that the procedure described did not contain enough safeguards to “take into account the possibility that an item of mail might get misplaced or lost anywhere between the CSA pool and the United States Post Office” (id.) The court also faulted the affiants for not indicating the basis for their knowledge that the office practice and procedure was followed, and the affiants failed to indicate that they were familiar with the defendant’s office practices and procedures when the first of the denials were allegedly mailed (id. at *3-4). Finally, the court indicated that neither of the affiants (who were in Ballston Spa and Melville) indicated from which office the denials were allegedly mailed, when the denials bore an address from Parsippany, New Jersey (id.).

Here, unlike the affiants in Acupuncture Prima Care, P.C., Jordan established personal knowledge of the standard mailing procedures in both Ohio and Colorado, based on training that Jordan received from the facilities at both Ohio and Colorado (Jordan aff ¶ 2). It is part of Jordan’s duties to ensure compliance with those procedures (id. ¶ 5). Unlike the affidavits in Acupuncture Prima Care, P.C., which did not state the office from which the denials were issued, Jordan provided information about the Envelope ID to establish that the denial was issued from Highland Heights, Ohio. In any event, the same court which decided Acupuncture Prima Care, P.C. acknowledged that its prior cases were no longer good law in light of St. Vincent’s Hospital of Richmond v Government Employees Insurance Co. (50 AD3d 1123 [2d Dept 2008]) (see Uniondale Chiropractic Off. v State Farm Mut. Auto. Ins. Co., 20 Misc 3d 1130[A], 2008 NY Slip Op 51687[U] [Dist Ct, Nassau County 2008]).

Defendant’s copies of the NF-3 Form that plaintiff submitted to defendant are date-stamped “Received Date: 05/22/2017” (see defendant’s exhibit C in support of motion), and plaintiff does not dispute that defendant received the bills on May 22, 2017. Even assuming, for the sake of argument, that the NF-3 Form was received on May 16, 2017, the same date on the NF-3 Form, defendant’s denial on May 31, 2017 was well within 30 days of defendant’s receipt of the bill.

Therefore, defendant met its prima facie burden that the claim was properly denied because the amount allowed was within the $200 policy deductible (Healthy Way Acupuncture, P.C., 54 Misc 3d 142[A], 2017 NY Slip Op 50204[U]; Innovative Chiropractic, P.C., 26 Misc 3d 135[A], 2010 NY Slip Op 50148[U]).

Plaintiff failed to raise a triable issue of fact warranting denial of summary judgment.^[FN2]

Therefore, defendant’s motion for summary judgment dismissing the complaint is granted.

“A no-fault provider establishes its prima facie entitlement to summary judgment by proof of the submission to the defendant of a claim form, proof of the fact and the amount of the loss sustained, and proof either that the defendant had failed to pay or deny the claim within the requisite 30-day period, or that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law”

(Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]). Once plaintiff meets its prima facie burden, the burden shifts to defendant “to show that it has a meritorious defense and that such a defense is not precluded” (Urban Radiology, P.C. v GEICO Gen. Ins. Co., 39 Misc 3d 146[A], 2013 NY Slip Op 50850[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013] [internal citation omitted]).

Here, any deficiencies in plaintiff’s proof of mailing were cured by defendant’s submission of the denial of claim form in defendant’s motion papers, which admitted receipt of the bill (Bob Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co., 53 Misc 3d 135[A], 2016 NY Slip Op 51434[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]; see Oleg Barshay, DC, P.C. v State Farm Ins. Co., 14 Misc 3d 74, 75 [App Term, 2d Dept, 2d & 11th Jud Dists 2006]).

However, plaintiff’s motion for summary judgment in its favor against defendant is denied. As discussed above, defendant timely denied the bill on the ground that the amount sought was within a $200 deductible.

CONCLUSION

Upon the foregoing cited papers, it is hereby ORDERED that plaintiff’s motion for summary judgment in its favor (Motion Seq. No. 001) is DENIED; and it is further

ORDERED that defendant’s cross motion for summary judgment dismissing the complaint (Motion Seq. No. 002) is GRANTED, and the complaint is dismissed, with costs and disbursements to defendant as taxed by the Clerk upon submission of an appropriate bill of costs; and it is further

ORDERED that the Clerk is directed to enter judgment in defendant’s favor accordingly.

This constitutes the decision and order of the court.

Dated: April 9, 2021

New York, New York

ENTER:

RICHARD TSAI, J.
Judge of the Civil Court

Footnotes

Footnote 1:The paragraphs in defendant’s affirmation in opposition to the motion and in support of the cross motion are misnumbered. The paragraphs are numbered sequentially from 1 through 11, but the paragraphs that follow are numbered 6 through 12. The citation here refers to latter numbering.

Footnote 2:As defendant points out, plaintiff’s affirmation in further support of motion and in opposition to defendant’s cross motion was purportedly served on January 14, 2020, past the December 26, 2019 agreed-upon deadline for opposition to cross motion (see defendant’s exhibit A in reply). However, the court will consider these papers, in the absence of any demonstrable prejudice to defendant (see Lawrence v Celtic Holdings, LLC, 85 AD3d 874, 875 [2d Dept 2011] [“Supreme Court did not abuse or improvidently exercise its discretion in considering the plaintiff’s untimely opposition papers inasmuch as the defendants were not prejudiced thereby”]).