Acupuncture fee schedule

New York’s no-fault insurance system establishes mandatory fee schedules that govern reimbursement rates for various healthcare services. When acupuncturists provide treatment to motor vehicle accident victims, insurance carriers frequently reduce payments by applying chiropractor fee schedule rates rather than the higher physician rates. This reimbursement methodology has generated substantial litigation, with healthcare providers challenging both the legal basis for these reductions and the proper application of fee schedules to specific service codes.

The regulatory framework underlying these disputes stems from 11 NYCRR 65-3.8, which establishes different reimbursement levels based on provider type. While the statute clearly authorizes reduced rates for standard acupuncture treatment codes, ambiguity arises regarding evaluation services, physical therapy modalities, and other ancillary procedures that acupuncturists commonly provide. Insurance carriers argue that all services rendered by acupuncturists should be paid at chiropractor rates regardless of the service type, while providers contend that non-scheduled services warrant different analysis.

Case Background

In Healthy Way Acupuncture P.C. v Metropolitan Property & Casualty Insurance Co., the First Department Appellate Term addressed whether the insurance carrier properly established its fee schedule defense through documentary evidence and testimony. The plaintiff acupuncture practice challenged payment reductions, arguing the carrier failed to meet its burden of proving proper fee schedule application. Metropolitan responded with an affidavit from its claims representative and excerpts from the applicable fee schedule.

The procedural issue centered on what evidence suffices to establish a prima facie case that fee schedule limitations were properly applied. Courts have developed specific evidentiary standards for these defenses, requiring carriers to demonstrate both the applicable fee schedule provisions and the correct methodology used to calculate reduced payments.

Jason Tenenbaum’s Analysis

Healthy Way Acupuncture P.C. v Metropolitan Prop. & Cas. Ins. Co., 2014 NY Slip Op 51127(U)(App. Term 1st Dept. 2014)

“Contrary to plaintiff’s assertion, the affidavit submitted by defendant’s claims representative, together with excerpts of the fee schedule of which we may take judicial notice (see Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co., 61 AD3d 13, 21 ), were sufficient to establish defendant’s proper calculation of the fees due under the schedule (see Natural Acupuncture Health, P.C. v. Praetorian Ins. Co., 30 Misc 3d 132, 2011 NY Slip Op 500410 ; see also GL Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 41 Misc 3d 131, 2013 NY Slip Op 51448 ).”

The real challenge with acupuncture fee schedule cases is not necessarily the reduction of the standard service codes to the chiropractor fee schedule rate.  The problem involves the evaluation codes and physical therapy codes that are not properly reduced.  While GL Acupuncture (my case – and if you read the record you would see that the initial visit was properly paid at the chiro rate) involved an initial service code paid at the chiropractic case, the newer issues involve the proper payments of other non-scheduled codes.

The consensus is to allow payment at the chiropractor rate for these services.

Legal Significance

The Appellate Term’s decision in Healthy Way Acupuncture reinforces the principle that courts may take judicial notice of fee schedules when evaluating summary judgment motions. This procedural ruling, following Kingsbrook Jewish Medical Center v Allstate Insurance Co., reduces the evidentiary burden on insurance carriers defending fee schedule reductions. Rather than requiring extensive expert testimony or detailed documentation, carriers can satisfy their prima facie burden through claims representative affidavits combined with fee schedule excerpts.

This evidentiary standard significantly impacts acupuncture providers’ ability to challenge payment reductions. The decision continues a judicial trend favoring streamlined resolution of fee schedule disputes, placing greater emphasis on regulatory compliance rather than case-by-case reasonableness determinations. However, the decision leaves unresolved questions about services that fall outside clearly defined fee schedule categories, particularly evaluation and management codes that may warrant physician-level reimbursement even when performed by acupuncturists.

Practical Implications for Practitioners

Healthcare providers billing no-fault carriers for acupuncture services must recognize that most standard treatment codes will be subject to chiropractor fee schedule limitations. However, strategic billing practices may preserve higher reimbursement for certain services. Evaluation codes, physical therapy modalities, and other ancillary services represent the frontier of fee schedule litigation, with courts yet to establish uniform standards for their treatment.

Practitioners should document the specific nature of evaluation services performed, distinguishing them from standard acupuncture treatments. When providing physical therapy modalities or other services that exceed traditional acupuncture scope, clear documentation supporting physician-level billing becomes essential. The evolving case law suggests that while standard acupuncture codes face settled reimbursement limitations, non-scheduled services may warrant different analysis depending on their nature and the provider’s qualifications.

Related Articles

• NY Acupuncture Prima Facie Defense: Chiropractor Rate Limitations Upheld
• NY Acupuncture Fee Schedules: Licensed Practitioners Limited to Chiropractor Rates
• Fee Schedule Defense Requirements in No-Fault Insurance Cases
• Understanding competent evidence for fee schedule defenses
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2014 post, New York’s no-fault fee schedules and regulations governing acupuncture services may have been amended through regulatory updates or legislative changes. The fee schedule rates, coding requirements, and payment methodologies for acupuncture services, including evaluation and physical therapy codes, should be verified against current Insurance Department regulations and recent court decisions interpreting fee schedule applications.