Why Trust This Analysis
This article is part of our ongoing fee schedule coverage, with 118 published articles analyzing fee schedule issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
In New York no-fault insurance disputes, insurance companies frequently assert that healthcare providers have overbilled by exceeding the applicable fee schedule rates. However, simply claiming that services exceed fee schedule limits isn’t enough — insurers must prove their position with proper documentation and calculations. This requirement becomes particularly important when dealing with specific CPT codes and the complex conversion factors that determine reimbursement rates.
The Appellate Term’s decision in Adelaida Physical Therapy demonstrates how courts scrutinize fee schedule defenses, especially when insurers fail to establish the foundational elements of their claims. This case highlights the ongoing challenges in New York no-fault insurance law regarding proper fee schedule calculations and the burden of proof required to sustain such defenses.
Jason Tenenbaum’s Analysis:
Adelaida Physical Therapy, P.C. v 21st Century Ins. Co., 2017 NY Slip Op 51808(U)(App. Term 2d Dept. 2017)
“Plaintiff properly argues on appeal that defendant failed to establish, as a matter of law, its defense that the fees charged with respect to the services billed under codes CPT 97010, 97110 and 97124 exceeded the amounts set forth in the workers’ compensation fee schedule therefor (see Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132, 2009 NY Slip Op 50732 ). Defendant failed to demonstrate that it had used the correct conversion factor in calculating the reimbursement rate. Consequently, the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for those services should have been denied.”
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Again, the Court has not been favorable of adjudicating these types of disputes as a matter of law.
Key Takeaway
Insurance companies asserting fee schedule defenses must do more than simply claim overcharges — they must prove they used correct conversion factors in their calculations. Courts remain reluctant to resolve these complex fee schedule disputes on summary judgment when insurers fail to establish proper foundational proof of their reimbursement rate calculations.
Legal Update (February 2026): Since this post’s publication in 2017, New York’s no-fault fee schedules and workers’ compensation fee schedules referenced for reimbursement calculations have undergone multiple revisions and updates. Additionally, regulatory amendments may have modified the evidentiary standards and procedural requirements for insurers asserting fee schedule defenses in no-fault disputes. Practitioners should verify current fee schedule provisions, conversion factors, and updated case law interpreting the burden of proof standards for such defenses.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
118 published articles in Fee Schedule
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a fee schedule matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
