Key Takeaway
New York court rules that chiropractor fee schedules apply to acupuncture services regardless of provider type, impacting no-fault insurance reimbursement rates.
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.
