Key Takeaway
New York court rules that chiropractor fee schedules apply to acupuncture services regardless of provider type, impacting no-fault insurance reimbursement rates.
This article is part of our ongoing fee schedule coverage, with 118 published articles analyzing fee schedule issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
Understanding how New York no-fault insurance law determines reimbursement rates can be complex, particularly when different types of healthcare providers perform similar services. A recent appellate decision highlights an important principle: the fee schedule that applies depends on the specific procedure codes billed, not necessarily the type of provider performing the service.
This ruling has significant implications for acupuncturists and other healthcare providers who may bill for services that fall under different professional fee schedules. The decision clarifies that insurance companies must apply the appropriate fee schedule based on the specific CPT codes submitted, which can affect reimbursement amounts and fee schedule disputes.
Jason Tenenbaum’s Analysis:
Gl Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 2013 NY Slip Op 51748(U)(App. Term 2d Dept, 2013)
“The claims had been denied on the ground that they exceeded the amount permitted by the workers’ compensation fee schedule, and that defendant had fully paid plaintiff for the services billed for in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors. Contrary to plaintiff’s assertion, an affidavit by defendant’s claims representative established that defendant had properly used the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which plaintiff was entitled to receive for the services at issue”
This was my case and the codes in issue were: 97810, 97811 and 99202. The bills were paid in accordance with what a chiropractor would be entitled to had (s)he billed for the services.
Key Takeaway
This decision establishes that fee schedule determination is based on the specific procedure codes billed rather than the provider’s primary profession. When acupuncturists bill using codes typically associated with chiropractic services, they receive reimbursement according to the chiropractor fee schedule, not the acupuncture fee schedule. This principle affects how providers structure their billing and expectations for reimbursement rates.
Legal Update (February 2026): New York no-fault fee schedules and reimbursement rates have been subject to multiple regulatory amendments and updates since this 2013 decision, including changes to CPT code classifications and provider-specific fee schedule applications. The interplay between different professional fee schedules may have evolved through subsequent appellate decisions and regulatory guidance. Practitioners should verify current fee schedule provisions and recent case law when analyzing reimbursement disputes involving cross-professional service billing.
Related Articles
Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
118 published articles in Fee Schedule
Keep Reading
More Fee Schedule Analysis
Acupuncture Reimbursements and Insurance Legalities Explained
Explore the Forrest Chen v. GEICO case and its impact on acupuncture insurance reimbursements in NY. Key insights for providers and patients.
Dec 11, 2024
Simple addition is insufficient
NY court rules simple addition insufficient to prove proper fee schedule calculations in no-fault insurance case, requiring detailed evidence of code utilization.
May 22, 2021
Fee Schedule Defenses in NY No-Fault Insurance: St. Vincent Med Care Case Analysis
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.
Dec 20, 2009
Fee Schedule/not precluded
Analysis of Oleg's Acupuncture v Hereford Insurance case examining fee schedule defenses, untimely denials, and certified medical coder affidavits in NY no-fault claims.
Jan 26, 2018
Amendment of 11 NYCRR 68.6 coming soon
New York proposes amending 11 NYCRR 68.6 to limit out-of-state no-fault health service reimbursement to highest NYS fee schedule rates for 2016.
Sep 30, 2016
8 units applies to billing medical providers only?
Suffolk County District Court rules on 8-unit billing limit for medical providers under NY no-fault insurance fee schedule, allowing reimbursement despite multiple claims.
Oct 27, 2013Common Questions
Frequently Asked Questions
What is the no-fault fee schedule?
New York's no-fault fee schedule, established by the Workers' Compensation Board and the Department of Financial Services, sets the maximum reimbursement rates that no-fault insurers must pay for medical services. When an insurer pays less than the billed amount, citing the fee schedule as a defense, the provider can challenge the reduction by demonstrating that the fee schedule was improperly applied or that the services are not subject to fee schedule limitations.
Can a medical provider charge more than the fee schedule allows?
Medical providers treating no-fault patients are generally limited to the amounts set by the fee schedule and cannot balance-bill the patient for the difference. However, certain services may not be covered by the fee schedule, and disputes about whether a specific service falls within the fee schedule are common in no-fault litigation. The Department of Financial Services periodically updates the fee schedule rates.
How are fee schedule disputes resolved in no-fault arbitration?
When an insurer partially pays a claim citing the fee schedule, the provider can challenge the reduction through no-fault arbitration. The provider must demonstrate that the service billed is not subject to the fee schedule or that the fee schedule was incorrectly applied. The insurer bears the burden of proving the fee schedule applies and the correct rate was used. Fee schedule disputes often involve coding issues, modifier usage, and applicability of Workers' Compensation rates.
Does the no-fault fee schedule apply to all medical services?
Not all medical services are subject to the no-fault fee schedule. Certain services, supplies, and procedures may fall outside its scope, in which case the provider may bill the usual and customary rate. Disputes about whether a specific service or billing code is covered by the fee schedule are common. The Workers' Compensation Board fee schedule and the Department of Financial Services ground rules guide which services are covered and at what rates.
Was this article helpful?
About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a fee schedule matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
