Acupuncture fee schedule defense upheld

Court Upholds Fee Schedule Limits in Acupuncture Billing Dispute

No-fault insurance billing disputes often center on whether healthcare providers can charge beyond established fee schedules. In Raz Acupuncture, P.C. v New S. Ins. Co., a New York court addressed this fundamental issue when an acupuncture practice challenged an insurance company’s denial of claims that exceeded workers’ compensation fee schedule amounts.

The case highlights the ongoing tension between healthcare providers seeking full compensation for their services and insurance companies applying statutory fee limitations. For practitioners in the no-fault insurance system, understanding these fee schedule restrictions is crucial for proper billing and avoiding claim denials. This decision reinforces that insurance carriers can successfully defend against claims that exceed established fee schedules when they follow proper denial procedures.

Jason Tenenbaum’s Analysis:

Raz Acupuncture, P.C. v New S. Ins. Co., 2012 NY Slip Op 50865(U)

“The affidavits submitted by defendant in support of its cross motion for summary judgment established that defendant had timely denied (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 ; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 ) plaintiff’s claims on the ground that the unpaid portion exceeded the amount permitted by the workers’ compensation fee schedule. Moreover, defendant demonstrated that it had fully paid plaintiff for the services in accordance with the workers’ compensation fee schedule.”

Another great appeal. Mr. Five Boro would be proud.

Key Takeaway

This ruling demonstrates that insurance companies can successfully defend fee schedule challenges when they properly deny claims and pay the permitted amounts. The court’s decision reinforces the importance of adhering to established fee schedules in workers’ compensation cases. Healthcare providers should be aware that claims exceeding these statutory limits face significant legal hurdles, as shown in this recent Mr. Five Boro victory.

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• Default judgment consequences in no-fault cases

Legal Update (February 2026): Since this 2012 decision, New York’s no-fault fee schedules and reimbursement regulations have undergone multiple revisions, including updates to both the no-fault fee schedule and workers’ compensation fee schedules referenced in acupuncture billing disputes. Additionally, procedural requirements for claim denials and the intersection between different statutory fee schedule frameworks may have been modified through regulatory amendments. Practitioners should verify current fee schedule provisions and denial procedures under the applicable regulations.