Government Employees Insurance v. Avanguard Medical Group, PLLC

49 N.E.3d 711, 27 N.Y.3d 22
New York Court of Appeals·Decided March 31, 2016·Published·Cited by 5 cases

Opinion

OPINION OF THE COURT

Rivera, J.

Defendant Avanguard Medical Group, PLLC claims that Insurance Law § 5102 requires a no-fault insurance carrier to pay a facility fee to a New York State-accredited office-based [25] surgery (OBS) center for the use of its physical location and related support services. We conclude that neither the applicable statutory nor regulatory frameworks mandate payment for OBS facility fees.

I.

Avanguard is a professional service limited liability company, accredited under New York’s Public Health Law as a facility for the provision of OBS, defined as “any surgical or other invasive procedure, requiring general anesthesia, moderate sedation, or deep sedation” performed “in a location other than a hospital” (Public Health Law § 230-d [1] [h]). Its owner is a medical doctor who conducts OBS procedures at Avanguard on patients covered under article 51 of the Insurance Law, enacted as the Comprehensive Automobile Insurance Reparations Act (see L 1973, ch 13), commonly referred to as the “No-Fault Law” (see Pommells v Perez, 4 NY3d 566, 570 [2005]). The doctor billed for his professional services through Metropolitan Medical & Surgical P.C., and separately billed for facility fees associated with his OBS services through Avanguard. According to Avanguard, the OBS facility fees are a charge for the use of the physical location and equipment, and also include payment for technicians and medical assistants who helped with the surgical procedures.

Plaintiffs, insurers Government Employees Insurance Co.; GEICO Indemnity Co.; GEICO General Insurance Co., and GEICO Casualty Co. (collectively GEICO), paid the doctor’s professional fees, but declined reimbursement for the facility fees. GEICO then commenced this action in Supreme Court for a declaratory judgment that GEICO is not legally obligated under Insurance Law § 5102 to reimburse Avanguard for OBS facility fees. The disputed fees total in excess of $1.3 million.

GEICO unsuccessfully moved to stay Avanguard’s pending arbitration and judicial actions, and for a preliminary injunction against any new filings (2012 NY Slip Op 31516[U] [Sup Ct, Nassau County 2012]). GEICO thereafter sought summary judgment, which Supreme Court also denied (2013 NY Slip Op 33849[U] [Sup Ct, Nassau County 2013]). The Second Department reversed and granted GEICO’s motion for summary judgment declaring GEICO is not required to reimburse Avanguard for OBS facility fees (127 AD3d 60 [2d Dept 2015]). Subsequently the Second Department dismissed GEICO’s appeal from the order denying the preliminary injunction as “aca[26] demic” (125 AD3d 803, 803 [2d Dept 2015]). We granted leave to appeal from the Appellate Division’s order granting GEICO’s motion for summary judgment (25 NY3d 907 [2015]).

II.

Avanguard asserts that pursuant to Insurance Law § 5102 (a) (1), OBS centers may recover a facility fee as a reimbursable “basic economic loss,” payable at a rate to be determined in accordance with 11 NYCRR 68.5. We reject Avanguard’s interpretation of the No-Fault Law framework, because it would permit Avanguard and other OBS centers to collect facility fees even though these types of fees are not expressly permitted by statute or payment schedules authorized thereby, and regardless of the fact that costs for the use of an OBS center are not reimbursable services under 11 NYCRR 68.5. Moreover, Avanguard’s view of the law undermines the obvious legislative purpose behind this framework, to contain costs by subjecting service charges to statutory ceilings and regulatory-fixed rates.

A. Legal Framework

Our analysis begins, as it must, with the statute. Indeed, “the text of a provision ‘is the clearest indicator of legislative intent and courts should construe unambiguous language to give effect to its plain meaning’ ” (Matter of Albany Law School v New York State Off. of Mental Retardation & Dev. Disabilities, 19 NY3d 106, 120 [2012], quoting Matter of DaimlerChrysler Corp. v Spitzer, 7 NY3d 653, 660 [2006]). In accordance with the No-Fault Law, automobile insurers, like GEICO, must provide up to $50,000 of coverage for an insured’s “basic economic loss” (Insurance Law § 5102 [a]), which includes,

“[a] 11 necessary expenses incurred for: (i) medical, hospital (including services rendered in compliance with article forty-one of the public health law, whether or not such services are rendered directly by a hospital), surgical, nursing, dental, ambulance, x-ray, prescription drug and prosthetic services; (ii) psychiatric, physical therapy (provided that treatment is rendered pursuant to a referral) and occupational therapy and rehabilitation; (iii) any non-medical remedial care and treatment rendered in accordance with a religious method of healing [27] recognized by the laws of this state; and (iv) any other professional health services” (Insurance Law § 5102 [a] [1]).

Expenses for basic economic loss, as described in this paragraph, “shall be in accordance with the limitations of” Insurance Law § 5108 (id.). Section 5108, titled “Limit on charges by providers of health services,” authorizes the Chair of the Workers’ Compensation Board to adopt fee schedules for basic economic losses, and mandates the Superintendent of the Department of Financial Services, in consultation with the Chair, to establish fee schedules “for all such services” not covered by the Chair’s schedules (Insurance Law § 5108 [b]).

Section 5108 also provides that basic economic loss service charges “shall not exceed the charges permissible” under the Chair’s schedule, “except where the insurer or arbitrator determines that unusual procedures or unique circumstances justify the excess charge” (Insurance Law § 5108 [a]). Furthermore, a health care provider may not “demand or request any payment in addition to the charges authorized pursuant to this section” under the Chair and Superintendent’s fee schedules (Insurance Law § 5108 [c]). Enforcement is, in part, facilitated by mandated self-regulation, which requires an insurer to report to the Commissioner of Health, among other improper conduct, “any patterns of overcharging, excessive treatment or other improper actions by a health provider” (id.). As this language illustrates, the legislature sought to cap payments and impose uniform fee rates in accordance with the regulatory schedules.

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Government Employees Insurance v. Avanguard Medical Group, PLLC, 49 N.E.3d 711, 27 N.Y.3d 22 (N.Y. 2016).

49 N.E.3d 711 (Government Employees Insurance v. Avanguard Medical Group, PLLC) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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