Key Takeaway
Analysis of St. Vincent Med Care v Country-Wide Insurance case regarding fee schedule defenses and bundled services in NY no-fault insurance claims for healthcare providers.
Understanding Fee Schedule Defenses in New York No-Fault Insurance Claims
In the complex world of New York’s no-fault insurance system, healthcare providers across Long Island and New York City frequently encounter challenges when seeking reimbursement for medical services. One such challenge involves understanding which services can be separately billed and which are considered bundled under existing procedures. A recent case from the Appellate Term provides valuable insight into this often-misunderstood area of no-fault law.
The St. Vincent Medical Care Case: A Deep Dive
St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. 2009 NY Slip Op 29508 (App. Term 2d Dept. 2009)
This case is more notable for the fact that it was decided prior to, yet published after “Infinity v. Eveready”, as well as Justice Golia’s scathing dissent regarding many of the same concerns that the Court of Appeals discussed 6 years ago in “Medical Society v. Serio.”
The issue that I am writing about is something that I am sure nobody noticed. It involved the defendant’s failure to prima facie prove its fee schedule defense. The court said the following:
“In opposition, defendant argued that it timely denied plaintiff’s claim seeking to recover the sum of $228.55 for services rendered on February 22, 2006 on the ground that the fee sought was in excess of the amount permitted by the workers’ compensation fee schedule because the services for which payment was sought were part of another service and, thus, were not separately reimbursable. Defendant established that it timely denied this claim”
It appears that the insurance carrier denied either muscle testing or range of motion testing based upon the worker’s compensation ground rule that prohibits compensation for certain services that are performed when an initial or follow-up evaluation is performed and paid. While many do not know this fact, this was the fee schedule issue that was presented in Rogy Medical, P.C. v. Mercury Ins. Co., 2009 NY Slip Op 50732(U)(App. Term 2d Dept. 2009), and it did not succeed.
The Broader Context: No-Fault Insurance in New York
New York’s no-fault insurance system was designed to provide prompt payment for medical expenses and lost wages regardless of who caused an automobile accident. However, the practical implementation of this system has created numerous challenges for healthcare providers, particularly those serving patients in densely populated areas like Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx.
The intersection of workers’ compensation fee schedules with no-fault insurance claims creates a particularly complex legal landscape. Insurance carriers often attempt to use workers’ compensation ground rules to limit reimbursement for certain medical services, arguing that specific procedures should not be separately compensated when performed as part of a comprehensive evaluation.
Key Legal Principles for Healthcare Providers
Understanding Bundled Services
The concept of bundled services in medical billing refers to situations where multiple procedures are considered part of a single, comprehensive service. In the context of no-fault insurance, this principle can significantly impact a provider’s ability to receive full reimbursement for all services rendered.
Muscle testing and range of motion testing are commonly performed diagnostic procedures that help healthcare providers assess a patient’s functional capacity and treatment needs. However, as demonstrated in the St. Vincent case, insurance carriers may argue these tests are inherently included in initial or follow-up evaluations and therefore not separately reimbursable.
The Prima Facie Case Requirement
For insurance carriers to successfully defend against a provider’s claim using fee schedule arguments, they must establish a prima facie case demonstrating that the services in question fall within the parameters of their defense. This requires more than simply asserting that certain services are bundled – it requires concrete evidence and proper legal foundation.
Practical Implications for Long Island and NYC Healthcare Providers
Healthcare providers throughout the New York metropolitan area should be aware of several key takeaways from this decision:
Documentation is Critical: Proper documentation of the medical necessity and independence of diagnostic procedures can help differentiate them from routine evaluation components.
Know Your Rights: Understanding when services can legitimately be billed separately versus when they may be considered bundled can help providers make informed billing decisions.
Challenge Improper Denials: Insurance carriers must meet their burden of proof when asserting fee schedule defenses. Providers should not simply accept denials without proper legal justification.
The Connection to Rogy Medical
The reference to Rogy Medical, P.C. v. Mercury Ins. Co. in the St. Vincent decision highlights an important pattern in no-fault insurance litigation. The Rogy case involved similar issues regarding the separate reimbursability of diagnostic services, and the unsuccessful outcome for the insurance carrier in that case provides additional context for understanding how courts approach these bundling arguments.
This interconnection between cases demonstrates the evolving nature of no-fault insurance law and the importance of staying current with judicial decisions that may impact billing practices and reimbursement expectations.
Frequently Asked Questions
What constitutes a valid fee schedule defense by an insurance carrier?
An insurance carrier must establish a prima facie case showing that the claimed services fall within the scope of their fee schedule limitations. This requires more than mere assertion – it requires evidence and proper legal foundation demonstrating that the services are indeed bundled or non-separately reimbursable under applicable regulations.
How do workers’ compensation fee schedules affect no-fault insurance claims?
Insurance carriers sometimes attempt to apply workers’ compensation ground rules to no-fault claims, arguing that certain services cannot be separately compensated when performed as part of a comprehensive evaluation. However, this application is not automatic and must be properly established by the carrier defending against the claim.
What should healthcare providers do when facing bundling arguments from insurance carriers?
Providers should carefully review the insurance carrier’s legal basis for their bundling argument, ensure proper documentation of medical necessity and service independence, and consider challenging denials that lack adequate legal justification. Consultation with experienced no-fault insurance attorneys can be valuable in these situations.
Are muscle testing and range of motion testing always considered bundled services?
Not necessarily. While insurance carriers may argue these services are included in routine evaluations, the specific circumstances of each case, proper documentation, and medical necessity can support their separate reimbursability. Each situation should be evaluated based on its individual merits.
How do these fee schedule issues affect patients receiving treatment?
When insurance carriers improperly deny reimbursement for legitimate medical services, it can create financial barriers for patients seeking necessary care. Proper resolution of these billing disputes helps ensure that patients have continued access to appropriate medical treatment without facing unexpected financial burdens.
Moving Forward: Best Practices for Providers
The St. Vincent case serves as an important reminder that insurance carriers must meet their burden of proof when asserting fee schedule defenses. Healthcare providers should not hesitate to challenge improper denials and should work with qualified legal counsel to protect their reimbursement rights.
For providers throughout Nassau County, Suffolk County, and New York City boroughs, staying informed about evolving no-fault insurance law is essential for maintaining a viable practice while ensuring patients receive necessary care.
If you’re a healthcare provider facing challenges with no-fault insurance reimbursement or need assistance understanding your rights under New York’s complex insurance regulations, professional legal guidance can make a significant difference in protecting your interests and ensuring proper compensation for your services.
Call 516-750-0595 to discuss your no-fault insurance legal needs with experienced professionals who understand the complexities of New York’s healthcare reimbursement system.
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Legal Update (February 2026): Since this 2009 analysis of fee schedule defenses, New York’s no-fault fee schedules and reimbursement regulations have undergone multiple amendments and updates. The Workers’ Compensation fee schedule referenced in the St. Vincent case has been revised several times, and procedural requirements for establishing fee schedule defenses may have evolved. Practitioners should verify current fee schedule provisions and defense requirements under the most recent regulations.
