Another acupuncture fee schedule challenge fails

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.

New York’s no-fault system incorporates multiple fee schedules depending on the type of service and the qualifications of the provider. For acupuncture services, the applicable fee schedule has been a source of ongoing litigation. Insurance carriers contend that acupuncture performed by chiropractors should be reimbursed according to the workers’ compensation fee schedule, which typically provides lower reimbursement rates than other applicable schedules. Providers argue that different fee schedules should apply, potentially yielding higher reimbursement.

Case Background

Health Needles Acupuncture, P.C. provided acupuncture services to a patient injured in a motor vehicle accident and sought payment from GEICO Insurance Company under the no-fault system. GEICO paid the claims but applied fee schedule reductions, reimbursing the provider at rates lower than the billed charges. The provider brought suit, arguing that GEICO’s fee schedule reductions were improper and that higher reimbursement rates should have applied.

GEICO defended its payment decisions, asserting that it had properly applied the workers’ compensation fee schedule for acupuncture services performed by chiropractors. The carrier moved for summary judgment, arguing that its fee schedule application was correct as a matter of law. The provider opposed the motion, challenging both the applicable fee schedule and GEICO’s methodology in applying it.

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”

Legal Significance

The Health Needles Acupuncture decision reinforces important principles governing fee schedule disputes in no-fault litigation. When insurance carriers properly document their application of applicable fee schedules, courts will uphold payment reductions even over providers’ objections. This judicial deference to properly applied fee schedules reflects policy judgments about containing healthcare costs while ensuring reasonable provider reimbursement.

The decision also clarifies that the workers’ compensation fee schedule applies to acupuncture services performed by chiropractors in the no-fault context. This cross-referencing of workers’ compensation fee schedules into no-fault payment determinations has been upheld consistently by New York courts. The regulatory framework explicitly incorporates workers’ compensation rates for certain services, creating a unified payment structure that prevents forum shopping and ensures consistent reimbursement.

The court’s analysis demonstrates the evidentiary burden carriers must meet to justify fee schedule reductions. GEICO successfully established that it applied the correct fee schedule and properly calculated payments under that schedule. This showing shifted the burden to the provider to demonstrate error in the carrier’s calculations or application. Without evidence of miscalculation or misapplication, the provider’s general objection to the fee schedule reduction failed.

Practical Implications

For insurance carriers, this decision confirms their authority to apply fee schedule reductions when supported by proper regulatory application. Carriers should maintain documentation showing which fee schedule applies to disputed services and how they calculated payments under that schedule. This documentation becomes critical if the payment decision is litigated.

Healthcare providers face an uphill battle when challenging fee schedule reductions. To succeed, providers must demonstrate either that the carrier applied the wrong fee schedule or miscalculated payments under the applicable schedule. Generic arguments that reimbursement rates are inadequate will not prevail. Providers should carefully review carriers’ fee schedule applications before pursuing litigation, ensuring they can identify specific errors rather than simply objecting to the rates themselves.

For acupuncture providers specifically, this decision confirms that services performed by chiropractors will be reimbursed at workers’ compensation rates. Providers should structure their billing and financial operations with this reimbursement reality in mind. Attempting to bill at higher rates may trigger disputes and litigation that providers are unlikely to win.

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.

Related Articles

• Acupuncture fee schedule (again)
• Fee schedule defense, Court separates 97811
• Chiropractor fee schedule applies to all billed for codes