Key Takeaway
Court ruling establishes that certified professional coder's affidavit can prove proper fee schedule application, potentially impacting arbitration arguments about coder qualifications.
In New York’s no-fault insurance system, disputes over medical fee schedules are common battlegrounds between healthcare providers and insurance companies. One recurring debate centers on whether insurance companies can rely on affidavits from certified professional coders to justify fee reductions, particularly when providers argue that only medical professionals should make such determinations.
This issue frequently arises in New York No-Fault Insurance Law cases where providers challenge fee schedule applications. The question becomes especially relevant in arbitration proceedings, where the sufficiency of evidence supporting fee reductions can determine case outcomes. Understanding how courts view coder qualifications is crucial for both providers seeking full reimbursement and insurers defending their payment decisions.
The professional coding process involves translating medical services into standardized codes and applying appropriate fee schedules. While this process requires specialized training, it doesn’t necessarily require medical licensure. Courts must balance the technical expertise of certified coders against arguments that medical judgment should be required for fee determinations.
Jason Tenenbaum’s Analysis:
GBI Acupuncture, P.C. v 21st Century Ins. Co., 2015 NY Slip Op 51235(U)(App. Term 2d Dept. 2015)
“Furthermore, the affidavit executed by defendant’s certified professional coder established that defendant had properly used the workers’ compensation fee schedule to determine the amount which plaintiff was entitled to receive for the services at issue”
I am sensing this case (among a few others) might cut into the argument (more so raised at arbitration) that the affidavit of the coder is insufficient to reduce the fee charged since the coder is not a medical professional.
Key Takeaway
This appellate decision validates the use of certified professional coder affidavits to support fee schedule applications, potentially undermining provider arguments that only medical professionals can justify payment reductions. The ruling suggests courts will accept technical coding expertise as sufficient evidence in fee disputes, which could impact strategy in both litigation and arbitration settings where fee schedule compliance is contested.
Legal Update (February 2026): Since this post’s publication in 2015, New York’s no-fault fee schedules and related regulations may have undergone significant revisions, including potential updates to coding requirements, acceptable documentation standards, and arbitration procedures. Additionally, subsequent court decisions may have further clarified or modified the standards for coder affidavit sufficiency in fee schedule disputes. Practitioners should verify current fee schedule provisions and recent case law developments when addressing coding-related reimbursement challenges.
