Key Takeaway
NY court confirms acupuncturists are limited to chiropractor fee schedule rates regardless of prior payments at higher medical doctor rates in no-fault insurance claims.
New York’s no-fault insurance system establishes specific fee schedules for different types of healthcare providers. These schedules determine the maximum reimbursement rates that insurance companies must pay for various medical services. A common dispute arises when licensed acupuncturists (L.ACs) seek payment at medical doctor rates rather than the lower chiropractor rates specified in the regulations.
The Appellate Term’s recent decision in Culex Acupuncture clarifies an important principle about fee schedule enforcement and estoppel claims. This ruling has significant implications for acupuncture practices operating under New York no-fault insurance law and reinforces established precedent regarding provider reimbursement rates.
Jason Tenenbaum’s Analysis:
Culex Acupuncture, P.C. v 21st Century Indem. Ins. Co., 2017 NY Slip Op 51145(U)(App. Term 2d Dept. 2017)
“Plaintiff’s sole argument on appeal, that the aforesaid branches of defendant’s motion [*2]should have been denied because defendant, without explanation, had paid the claims at issue at the rate for acupuncture services performed by a chiropractor, but paid other claims at the rate for acupuncture services performed by a medical doctor, is without merit (see Apple Tree Acupuncture, P.C. v Progressive Northeastern Ins. Co., 36 Misc 3d 153, 2012 NY Slip Op 51710 )”
Again, the court has held that all an L.AC is entitled to is the chiropractor fee schedule, regardless of what it bills. Prior payment at the MD rate does not create an estoppel.
Key Takeaway
The court’s decision establishes that licensed acupuncturists cannot claim entitlement to higher medical doctor rates based on inconsistent prior payments by insurance companies. Even when insurers previously paid claims using MD rates, this does not create a legal estoppel preventing them from applying the correct chiropractor fee schedule rates going forward. This reinforces the regulatory framework governing fee schedule determinations in no-fault cases.
Legal Update (February 2026): Since this 2017 post, New York’s no-fault fee schedules and reimbursement regulations may have been modified through regulatory amendments or updates to the Insurance Department’s fee schedule provisions. Additionally, subsequent court decisions may have further clarified the application of estoppel principles in provider reimbursement disputes. Practitioners should verify current fee schedule rates and recent case law developments when advising on acupuncture reimbursement matters.
