The Comptroller has the authority to review and report on the billing practices of a medical provider not a participating physician within the NYSHIP Empire Plan network

The Comptroller has the authority to review and report on the billing practices of a medical provider not a participating physician within the NYSHIP Empire Plan network

Martin H. Handler, M.D., P.C. v DiNapoli, 2014 NY Slip Op 03191, Court of Appeals

Among the patients treated by a physician and a medical group [Providers] were individuals insured by the Empire Plan, New York State's primary health benefit plan. The Empire Plan pays about 80% of the charges billed for the medical services provided to individuals covered by the Empire Plan. Providers challenged the authority of the State Comptroller to review their records as part of an audit of billing practices in the health care industry for claims paid by the Empire Plan

The Comptroller contended that he had the authority to review and otherwise report on medical provider’s billing practices as part of its audit of State expenditures. The Court of Appeals agreed.

Among the issues considered by the court were “co-payments” incorporated in the fee structure.

Participating providers have an agreement with United that specifies the fees they may charge. These providers bill claims, less a patient “co-pay,” to United Healthcare Insurance of New York [United] which processes and pays claims made by Empire Plan beneficiaries. In contrast, non-participating providers charge market rates for their services and bill the patient directly. United then reimburses the patient 80% of either the actual fee charged or the "customary and reasonable charge" for the service, whichever is lower. The patient is responsible for paying the provider’s bill, including the 20% that is not paid by United, from his or her personal funds.

Non-participating providers have a legal duty to collect patients' co-payments and failure to collect these fees can result in civil and criminal penalties for insurance fraud.*  

According to the decision, the non-participating provider's failure to collect a co-payment from an Empire Plan member inflates a claim's cost and adversely impacts the State's fisc. A provider that charges $100 for a service, and who collects $80 in State money, must collect $20 from the Empire Plan member. In the event that the provider does not collect the co-payment, it has provided a medical service for $80, not $100, and the State should have paid only $64 of that cost.

After the Comptroller had examined Providers billing records for certain periods of time, the auditors found Providers routinely waived the co-pay that was to be paid by Empire patients and that this resulted in more than $1.500,000 in overpayments by United during this period. The Comptroller recommended that United recover the overpaid sums of money, advise Providers of the advantages of participating in the Empire Plan, and contact the Department of Civil Service to develop a plan for preventing future waiver of required co-payments. The Comptroller took no independent enforcement action.

Providers then filed separate combined Article 78 and declaratory judgment actions against the Comptroller and United, challenging the Comptroller's authority to audit their books and sought judicial relief that included enjoining publication of the results of the audit and enjoining United from collecting any alleged overpayments.

Supreme Court granted the petitions in part and enjoined United from taking action based on the Comptroller’s audit results. In separate decisions, Supreme Court concluded that the Comptroller lacked constitutional authority to audit Providers because Providers are "not a political subdivision of the State."

The Appellate Division found the Comptroller has a constitutional duty to audit payments made by the State, and, as a part of that duty, the Comptroller has the authority to conduct post-audit reviews of payments made to Providers. The Appellate Division explained that were the Comptroller to lack authority to audit health care providers' payment records, "no other entity . . . would retain oversight" to prevent overpayments that result from waived co-insurance fees. The Appellate Division remitted the cases to Supreme Court for further proceedings to address Providers’ claims that the audit findings were arbitrary and capricious and lacked a rational basis. Supreme Court dismissed Providers’ petitions and they appealed to the Court of Appeals ”as of right under CPLR 5601(d), bringing up the prior orders of the Appellate Division, which involved a substantial constitutional question.” 

Providers contended that the Comptroller's audits exceeded the constitutional limitations on its powers because, as non-participants in the Empire Plan, they neither have a contract with the State nor receive State funds, and the Comptroller cannot audit them. 

Under the current provisions of law, the Comptroller is to audit State payments and receipts and the Legislature is prohibited from assigning administrative tasks to the office in order to protect "the independent character of the Comptroller's audit function."

Further, Civil Service Law §167 (7), provides that the Comptroller is to audit payments to the State's health insurance vendors whereby "The amounts required to be paid to any contracting corporation under any contract [with NYSHIP] shall be payable from such health insurance fund as audited by and upon the warrant of the comptroller[.]"

Thus, said the court, both the Constitution and statutes require the Comptroller to ensure proper billing and payment for the Empire Plan. In order to accomplish its legally mandated duties to prevent unauthorized payments and overpayments, the Comptroller must perform both pre- and post-audit review of Empire Plan payments.

The Court of Appeals rejected Providers’ theory that United’s role as a conduit severs any connection between the State funds and the their billing practices, putting the records beyond the Comptroller's reach, explaining that the Constitution does not limit the Comptroller's authority in this way and the fact that the State relies on a third-party conduit, United, does not change the character of the funds.

Holding that the Comptroller's limited examination of Providers' billing records amounted to a post-audit of State payments and was permitted by the Constitution, the Court of Appeals ruled that the judgments of Supreme Court and the prior orders of the Appellate Division reviewed should be affirmed, with costs.

* (see Insurance Law §403 [c]; Penal Law § 176.05 [2]).

The decision is posted on the Internet at:

http://www.nycourts.gov/reporter/3dseries/2014/2014_03191.htm
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Disciplinary arbitrator’s treating one individual differently or less favorably than another similarly situated individual is not a reason to vacate the arbitration award.

Disciplinary arbitrator’s treating one individual differently or less favorably than another similarly situated individual is not a reason to vacate the arbitration award.

2014 NY Slip Op 03265, Appellate Division, Second Department

MTA Bus Co. had a policy banning cell-phone use while operating a bus. After the bus driver allegedly violated the MTA’s cell-phone policy three separate occasions and, in accordance with that policy, he had been suspended from employment for a period of 10 days.

Following the bus driver's fourth violation MTA terminated his employment. 

The bus driver’s union filed a grievance challenging the termination, and an arbitration hearing was conducted. After the hearing, the arbitrator concluded that the bus driver had committed a "cell phone violation," and that MTA's decision to terminate his employment was proper. The bus driver filed and Article 75 petition seeking a court order vacating the arbitration award.

Supreme Court denied the petition, in effect confirming the award and the bus driver appealed, contending that the arbitration award was irrational.

The Appellate Division, noting that "Judicial review of an arbitrator's award is extremely limited" said a court may vacate an arbitration award pursuant to CPLR 7511(b)(1)(iii) "only if it violates a strong public policy, is irrational, or clearly exceeds a specifically enumerated limitation on the arbitrator's power." Further said the court, "Courts are bound by an arbitrator's . . . judgment concerning remedies [and] cannot examine the merits of an arbitration award and substitute its judgment for that of the arbitrator simply because it believes its interpretation would be the better one." In addition the court commented that the fact “That the arbitrator may have treated the petitioner differently or less favorably than another similarly situated bus driver is not a ground to vacate the arbitration award.”

The Appellate Division held that the arbitrator's award was justified and, hence, rational as the record showed that the bus driver was aware of MTA’s cell-phone policy and had been previously suspended for 10 days for violating that policy. The court explained that violation of the MTA's cell-phone policy, which also violates New York law, constitutes appropriate grounds for termination of employment.

The decision is posted on the Internet at:

http://www.nycourts.gov/reporter/3dseries/2014/2014_03265.htm
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On the Blogs: REAL-NY

On the Blogs: REAL-NY

On the Internet at: http://realny.org/

Powered by the legal information website, LawHelpNY, REAL-NY is a is a public-interest news blog that focuses on stories and organizations that matter to the lives of low-income New Yorkers in general and to access to justice in particular.

The Blog stories and resources that may help people solve problems and bring attention to issues that need more attention.  Built around a community service media model, this blog targets low-income New Yorkers and the community groups, nonprofits, and government agencies that assist them.

Using the power of design, multi-media, discussion forums, online polls, and short and informative plain- it posts articles to help New Yorkers learn about their legal rights as they apply to current events and community resources.

REAL-NY provides general information only. To find a lawyer in your area please visit http://www.lawhelpny.org/ and select a topic which best covers your legal problem.

For more information, contact the Technology Innovations Manager at LawHelpNY, Wilneida Negron at wnegron@nylawhelp.org.
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A collective bargaining agreement may obligate the employer to paying certain legal expenses incurred by an employee in the negotiating unit

A collective bargaining agreement may obligate the employer to paying certain legal expenses incurred by an employee in the negotiating unit

Local 342, Long Is. Pub. Serv. Employees v Huntington, 2014 NY Slip Op 03271, Appellate Division, Second Department

Public Officers Law §18*permits a political or civil subdivision of the State whose governing body has agreed by the adoption of local law, by-law, resolution, rule or regulation to “confer the benefits of the section” upon its employees, and (ii) to be held liable for the costs incurred under these provisions including the defense and indemnification its officers and employees, other than the sheriff of any county or an independent contractor.

This provision may be triggered in any civil action or proceeding, state or federal, arising out of any alleged act or omission which occurred or allegedly occurred while the officer or employee was acting within the scope of his or her public employment or duties.

However, this duty to provide for a defense does not arise where such civil action or proceeding is brought by or on behalf of the public entity employing such employee.

As the Local 342 decision demonstrates, a political or subdivision of the State may also obligate itself to be liable for such costs by including such an obligation in a collective bargaining agreement.

An arbitrator determined that the Town of Huntington had breached a provision in a collective bargaining agreement by failing to pay certain legal fees on behalf of an employee in the collective bargaining unit.

The Appellate Division said that Supreme Court properly concluded that the arbitrator's determination did not clearly violate a strong public policy, was not totally or completely irrational, and did not manifestly exceed a specific, enumerated limitation on the arbitrator's power.

The court explained that although the payment of a public employee's legal fees "would constitute an impermissible donation from the public purse in instances where there is no prior legal obligation on the part of the State or a municipality to provide reimbursement, the reimbursement is proper and considered additional remuneration where there is a prior legal obligation" to do so.

In this instance, said the Appellate Division, the relevant collective bargaining agreement expressly created a prior legal obligation on the part of the Town to pay the subject legal fees incurred by the individual.**

* Public Officers Law §17, provides for the defense and indemnification of officers and employees of the State as the employer by the State. .

** See Civil Service Law Section 204-a

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The decision is posted on the Internet at:

http://www.nycourts.gov/reporter/3dseries/2014/2014_03271.htm
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A public employer may impose restraints on First Amendment activities of its employees that are job-related that would be unconstitutional if applied to the public at large

A public employer may impose restraints on First Amendment activities of its employees that are job-related that would be unconstitutional if applied to the public at large

Santer v Board of Educ. of E. Meadow Union Free Sch. Dist., 2014 NY Slip Op 03189, Court of Appeals

Members of a teachers' union picketing on a public street in front of a district school) displayed picketing signs from their cars parked where parents were dropping their children off at school district’s Woodland School. East Meadow Union Free School District brought disciplinary charges for misconduct against certain teachers, alleging that the teachers had created a health and safety risk by parking their cars so that students had to be dropped off in the middle of the street instead of at curbside.

After their respective hearings, the arbitrators found the teachers guilty of the misconduct charge and imposed a fine as the penalty. The arbitrators, acknowledging that the parking demonstration was conducted on public property while teachers were off-duty, and that their cars were legally parked, nonetheless concluded that teachers "intended to (and did) disrupt the student drop off and that the parked cars created a health and safety risk to children who had to be dropped off in the middle of a busy street in the rain." The Court of Appeals noted that although it was "fortunate" that no child was injured, the arbitrators determined that fact was irrelevant to their findings that teachers’ intentional conduct posed a potential threat to student safety.

The teachers than sued, seeking to vacate the arbitration awards in which they were found guilty of misconduct, contending that the disciplinary proceedings commenced against them, and the discipline ultimately imposed them, a fine, violated their right to free speech under the First Amendment to the United States Constitution.

Supreme Court denied the petitions but the Appellate Division reversed in each case. Applying the two-part balancing test from Pickering v Board of Educ. of Township High School Dist. 205, Will County Ill, 391 US 563,* the. Appellate Division decided that the teachers’ speech addressed a matter of public concern and, second, that the District failed to meet its burden of demonstrating that teachers' exercise of their free speech rights "so threatened the school's effective operation as to justify the imposition of discipline."

Although the Court of Appeals said it agreed with the Appellate Division with respect to the picketing demonstration, a form of "speech" protected by the First Amendment, addressed a matter of public concern, it disagreed with the Appellate Division’s conclusions with respect to the second step of the Pickering test and reversed the lower courts’ rulings.

The Court of Appeals said that viewing the record evidence in light of established federal precedent, it concluded that “the teachers' interests in engaging in constitutionally protected speech in the particular manner that was employed on the day in question were outweighed by the District's interests in safeguarding students and maintaining effective operations at Woodland.”

The school district, said the court, also satisfied its burden of proving that the discipline imposed here was justified because the teachers created a potential yet substantial risk to student safety and an actual disruption to school operations.

Addressing the Free Speech argument advanced by the teachers, the Court of Appeals said that “It is well settled that a public employer may not discharge or retaliate against an employee based on that employee's exercise of the right of free speech” but “Equally well settled, however, is that ‘the State has interests as an employer in regulating the speech of its employees that differ significantly from those it possesses in connection with regulation of the speech of the citizenry in general,’" citing Pickering,

Accordingly, said the court, public employers "may impose restraints on the First Amendment activities of its employees that are job-related even when such restraints would be unconstitutional if applied to the public at large." Thus, although "public employees like . . . teacher[s] do not leave their First Amendment rights at the schoolhouse door, . . . it is plain that those rights are somewhat diminished in public employment." Accordingly, the Court of Appeals, holding that the teachers’ demonstration constituted "speech" subject to First Amendment strictures, considered “that speech” in the context of the Pickeringbalancing test.

On the record, said the court, the teachers’ speech was on a matter of public concern and entitled to First Amendment protection. It then moved on the the “second test,” weighing the employee's First Amendment rights against the public employee's interest " in promoting the efficiency of the public services it performs through its employees'.

The interests the District asserted: “ensuring the safety of its students and maintaining orderly operations at Woodland” are legitimate said the court. As the evidence at the hearings showed that the parking demonstration created dangerous traffic conditions in front of the school that could have injured a student and that caused actual disruption to the school's operations, the school district contented that this was sufficient to justify its discipline of the teachers and that it was not required to prove that a student was actually injured for the Pickering balance to tip in the District's favor.

The majority of the Court of Appeals agreed and reversed the Appellate Division’s ruling, with costs and confirmed the arbitration award.

N.B. Justice Smith concurred but “only in the result, because [he did] not agree with the majority's view that the conduct of these teachers was speech or expression protected by the First Amendment,”  stating that he was “troubled by the implication that intentionally disruptive and dangerous conduct can, if it is designed for the purpose of calling attention to the actor's message, qualify for First Amendment protection.” In contrast, Justice Rivera dissented, stating that “I dissent from the majority's decision because I can find no legal or factual error in the Appellate Division's application of the Pickering balancing test to the facts of these cases. I would affirm the Appellate Division's orders and its conclusion that the District violated the teachers' free speech rights.”

* A summary of Pickering, “Essentials of the "Pickering Balancing Test” was posted earlier on NYPPL at http://publicpersonnellaw.blogspot.com/2010/01/essentials-of-pickering-balancing-test.html

The decision is posted on the Internet at:

http://www.nycourts.gov/reporter/3dseries/2014/2014_03189.htm
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