Key Takeaway
New York court upholds GEICO's fee schedule reductions for acupuncture services, rejecting provider's challenge in workers' compensation case.
Healthcare providers in New York’s no-fault insurance system often challenge insurance carriers’ payment decisions, particularly when reimbursements fall short of billed amounts. One common battleground involves fee schedule reductions, where insurance companies apply predetermined payment rates that may be lower than what providers charge. These disputes frequently center on whether the carrier properly applied the appropriate fee schedule and whether the reductions were justified under New York’s regulatory framework.
The case of Health Needles Acupuncture, P.C. v GEICO Insurance Co. illustrates how courts evaluate these fee schedule challenges. Acupuncture providers face unique challenges in the no-fault system, as their services often fall under specific billing codes and payment structures. Understanding how courts analyze CPT Code 97813 and 97814 billing disputes can be crucial for both providers and patients seeking coverage. When insurance carriers reduce payments based on fee schedules, they must demonstrate that their reductions comply with applicable regulations and that they’ve properly applied the correct payment methodology.
Jason Tenenbaum’s Analysis:
Health Needles Acupuncture, P.C. v GEICO Ins. Co., 2014 NY Slip Op 51864(U)(App. Term 2d Dept. 2014)
“On appeal, plaintiff argues that defendant failed to establish that its fee schedule reductions were proper. We disagree and find that defendant demonstrated that it had fully paid plaintiff for the services at issue in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors”
Key Takeaway
This decision reinforces that insurance carriers can successfully defend fee schedule reductions if they demonstrate proper application of the applicable payment methodology. The court’s ruling shows that when carriers follow established fee schedules—in this case, the workers’ compensation schedule for acupuncture services—providers face an uphill battle in challenging payment reductions. Healthcare providers must carefully evaluate whether fee schedule applications are truly improper before pursuing litigation.
Legal Update (February 2026): New York’s no-fault fee schedules for acupuncture services have been subject to regulatory amendments and updates since this 2015 post, particularly regarding CPT codes 97813 and 97814 reimbursement rates and billing procedures. Practitioners should verify current fee schedule provisions and payment methodologies, as both state regulations and insurance carrier practices may have evolved significantly over the past decade.
