Key Takeaway
New Jersey fee schedule requirements for NY no-fault claims when providers perform services outside New York State under 11 NYCRR § 68.6 prevailing fee regulations.
Epic Pain Mgt. & Anesthesia Consultants, LLC v New York Cent. Mut. Fire Ins. Co., 2014 NY Slip Op 51391(U)(App. Term 1st Dept. 2014)
“Defendant’s moving submission below relied exclusively on a worker’s compensation fee schedule defense, and failed to address, much less refute the applicability of Insurance Department regulation (11 NYCRR) § 68.6, which provides that where, as here, a reimbursable health service “is performed outside New York State, the permissible charge for such service shall be the prevailing fee in the geographic location of the provider.” Notably absent from defendant’s moving papers was any discussion of the proper “geographic location” of the plaintiff provider — which apparently maintains offices in both New York and New Jersey — or of the “prevailing fee” were such location determined to be in New Jersey”
What is the “prevailing fee”? Is it the New Jersey fee schedule or something else? Unsure. I think Nassau Anesthesia Assoc. P.C. v Chin, 32 Misc.3d 282 (Dis. Ct. Nassau Co. 2011) is relevant on this point: “To the contrary, as recognized in Temple Univ. Hosp., Inc. v Healthcare Mgt. Alternatives, Inc. (832 A2d 501 ), the amounts “actually received” by medical providers from insurers are a far better indicator of the reasonable value of a provider’s services than the “full published charged” unilaterally set by the provider. (832 A2d at 508-510.)”
Related Articles
- Cross-border medical fee schedules between New York and New Jersey
- Fee schedule defense requirements and competent evidence standards
- Understanding medical billing and down-coding in no-fault insurance claims
- Competent evidence requirements 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 out-of-state providers may have been substantially revised. Practitioners should verify current provisions of 11 NYCRR § 68.6 and any updated guidance on determining “prevailing fees” for services performed outside New York State, as regulatory amendments and interpretive decisions may have clarified these standards.
