Key Takeaway
Court ruling establishes that a certified medical coder's affidavit provides sufficient evidence to support workers' compensation fee schedule defenses in summary judgment motions.
Understanding Fee Schedule Defenses in Workers’ Compensation Cases
When healthcare providers submit claims for workers’ compensation benefits, insurance carriers often defend against overpayment allegations by citing compliance with established fee schedules. A recent appellate court decision clarifies what evidence insurers need to successfully establish this defense, particularly regarding the sufficiency of certified medical coder testimony.
The workers’ compensation fee schedule sets maximum reimbursement rates for medical services, similar to how New York No-Fault Insurance Law governs payment standards in auto accident cases. Understanding the evidentiary requirements for fee schedule defenses is crucial for both healthcare providers and insurance carriers navigating these disputes.
Jason Tenenbaum’s Analysis:
Precious Acupuncture Care, P.C. v Hereford Ins. Co., 2018 NY Slip Op 50042(U)(App. Term 2d Dept. 2018)
” Plaintiff moved for summary judgment, and defendant cross-moved for summary judgment dismissing the complaint on the ground that plaintiff sought to recover amounts which were in excess of the amounts permitted by the workers’ compensation fee schedule. Defendant supported its cross motion with an affidavit by its certified medical coder and biller, which affidavit was sufficient to establish, prima facie, that defendant had fully paid the claims in accordance with the fee schedule”
Workers compensation fee schedule defense is satisfied through the affidavit of a certified medical coder.
Key Takeaway
This decision establishes that insurance carriers can successfully defend against workers’ compensation overpayment claims using affidavits from certified medical coders and billers. The court found such testimony sufficient to create a prima facie case that payments complied with applicable fee schedules, streamlining the defense process for carriers facing summary judgment motions.
Related Articles
- Understanding Medical Billing and Down-Coding in New York No-Fault Insurance Claims
- Fee Schedule Defense Requirements in No-Fault Insurance Cases
- Competent evidence requirements for fee schedule defenses
- NY Acupuncture Fee Schedules: Licensed Practitioners Limited to Chiropractor Rates
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2018 post, New York’s workers’ compensation fee schedules and reimbursement methodologies may have been subject to regulatory amendments or updates. Additionally, evidentiary standards for certified medical coder testimony in fee schedule disputes may have evolved through subsequent appellate decisions. Practitioners should verify current fee schedule provisions and recent case law developments when relying on certified medical coder evidence in workers’ compensation overpayment defenses.
