Jing Luo Acupuncture, P.C. v NY City Tr. Auth., 2018 NY Slip Op 51083(U)(App. Term 2d Dept. 2018)
(1) “We have held, as a matter of law, that the workers’ compensation fee schedule for acupuncture services performed by chiropractors is the appropriate fee schedule for insurers to use to determine the amount which a licensed acupuncturist is entitled to receive for acupuncture services”
(2) “As defendant argues, 11 NYCRR 65-3.8 (g) (1) (ii), effective April 1, 2013 (see 11 NYCRR 65-3.8 [g] [2]), provides that “no payment shall be due for . . . claimed medical services under any circumstances . . . for those claimed medical service fees that exceed the charges permissible pursuant to Insurance Law sections 5108 (a) and (b) and the regulations promulgated thereunder for services rendered by medical providers” (see also Oleg’s Acupuncture, P.C. v Hereford Ins. Co., 58 Misc 3d 151[A], 2018 NY Slip Op 50095[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2018]). Thus, the Civil Court incorrectly denied defendant’s cross motion on the ground that defendant was precluded from interposing its fee schedule defense.”
(3) “Defendant demonstrated that it had fully paid plaintiff in accordance with the workers’ compensation fee schedule for the services billed under CPT codes 97811, 97813 and 97814 for acupuncture services that plaintiff had rendered from August through November 2013.”
(4) “Defendant has not demonstrated, as a matter of law, its defense that the fees charged with respect to the services billed under CPT code 99262 exceeded the amounts set forth in the workers’ compensation fee schedule therefor ”
Well, once again the chiro rate prevails and some initial code that was used was not paid at the applicable chiro fee schedule or properly reduced and paid. In addition, there is no preclusion for a fee schedule defense post April 2013. Re-inventing the wheel.
