Fee schedule defense: Court separates 97811, 97813, 97814 from remainder of case

In New York’s complex no-fault insurance system, healthcare providers and insurance companies frequently clash over appropriate reimbursement rates for medical services. One particularly contentious area involves acupuncture services and which fee schedule should govern payment rates. The case of Z. M. S. & Y Acupuncture, P.C. v GEICO demonstrates how courts handle disputes when insurance companies invoke alternative fee schedules as a defense against provider claims.

This decision highlights an important procedural aspect of no-fault litigation: courts can separate different aspects of a case when distinct legal issues are involved. Here, the court allowed the insurance company’s fee schedule defense to proceed for specific acupuncture CPT codes while keeping the remainder of the case intact. The ruling also reinforces the significance of timing in no-fault disputes, particularly regarding when certain regulatory defenses became available to insurance carriers.

Jason Tenenbaum’s Analysis:

Z. M. S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co., 2017 NY Slip Op 51891(U)(App. Term 2d Dept. 2017)

(1) ” Defendant appeals from so much of an order of the Civil Court as denied the branches of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT codes 97811, 97813 and 97814.”

(2) “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 (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 ). Since the services here were rendered after April 1, 2013, the defense that the amounts sought to be recovered exceed the amount permitted by the workers’ compensation fee schedule is not subject to preclusion (see 11 NYCRR 65-3.8 Apr. 1, 2013]; Surgicare Surgical Assoc. v National Interstate Ins. Co., 50 Misc 3d 85 ).”

Key Takeaway

This ruling establishes that insurance companies can successfully defend against acupuncture provider claims by demonstrating payment according to workers’ compensation fee schedules rather than standard no-fault rates. Critically, this defense is available for services rendered after April 1, 2013, when regulatory changes eliminated the preclusion of such fee schedule arguments, giving insurers broader latitude in challenging provider billing practices.

Related Articles

• The CPLR 3212(g) paradigm
• Understanding CPLR 3212(a): Critical Timing Rules for Summary Judgment Motions in New York
• The amendments to the regulations and what they mean to you
• No-Fault Verification Requirements: When Partial Compliance Isn’t Enough
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2017 decision, New York’s no-fault fee schedules under 11 NYCRR Part 65 have undergone multiple amendments and updates. Practitioners should verify current provisions regarding acupuncture reimbursement rates, applicable fee schedule classifications, and any procedural changes affecting fee schedule defense timing requirements.