Key Takeaway
Quality Comprehensive v NY Central Mutual: coder proof supported only partial dismissal in a no-fault case, not a workers' compensation ruling.
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.
The decision discussed here is Quality Comprehensive Medical Care v New York Central Mutual, 2019 NY Slip Op 51734(U), decided October 25, 2019. An earlier version of this page misattributed the passage to Sama Physical Therapy, a supporting citation in the opinion. This was a no-fault case, not a workers’ compensation proceeding.
Historical note: Quality Comprehensive (2019) supports only partial dismissal for the proved excess; the DFS schedule guidance should be used to identify the rules applicable to later services.
Last reviewed: September 2026.
The coder proved only part of the defense
The insurer’s certified professional coder supported its position that the provider’s charges exceeded the applicable fee schedule. But the insurer failed to establish its separate lack-of-medical-necessity defense. The Appellate Term, Second Department, therefore modified the order: dismissal extended only to the fee excess, not the entire claim.
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The provider’s cross-motion for summary judgment remained denied. Neither side’s failure on one issue established that the other side had proved every element of its own motion.
Why the distinction matters
A fee calculation concerns the permissible charge. A medical-necessity defense asks a different question and needs its own proof. Quality Comprehensive did not hold that a coder’s affidavit establishes both, or that certification by a named organization is a universal admissibility requirement.
The use of a workers’ compensation schedule in calculating no-fault reimbursement does not change the type of action. Insurance Law § 5108 supplies the statutory fee framework; this appeal does not decide benefits due to an injured worker or value a personal injury settlement.
Connect to the Encyclopedia
Start with the fee-schedule defense hub. Related case notes:
- Urban Well: coding corrections and separate necessity proof.
- OS Tigris: an unsupported fee-schedule defense.
- Excel Surgery: New Jersey treatment and the service date.
- Healing Art: agreed coder testimony on codes 97810 and 97811.
- New Age: the denied motion on CPT 97026.
- Precious Acupuncture: coder proof and post-2013 preclusion.
- Acuhealth: the missing by-report verification request.
For review of a particular no-fault billing dispute, contact the Law Office of Jason Tenenbaum. Bring the bill, service dates, denial and payment calculation.
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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Nov 24, 2019Frequently Asked Questions
Common Questions About This Topic
5 answers from the firm's New York personal-injury and employment-law practice. Click any question to expand.
What qualifications should a certified medical coder have to testify as an expert witness?
The opinion accepted a certified professional coder's affidavit on its record. It did not require a particular credentialing organization for every witness or hold that certification alone supplies a sufficient foundation.
How do medical coding errors affect personal injury settlements?
Quality Comprehensive did not decide settlement value. It addressed the allowable amount of an assigned no-fault bill; no settlement estimate follows from its coding ruling.
Can medical providers be held liable for incorrect coding practices?
The opinion made no fraud or liability finding against the provider. An alleged coding error is not, by itself, proof of fraud or malpractice.
How do workers’ compensation fee schedules differ from standard medical billing?
Insurance Law § 5108 uses the workers' compensation schedule framework to limit covered no-fault charges, subject to its provisions. That does not make a no-fault billing suit a workers' compensation case.
What should attorneys look for when challenging medical coder expert testimony?
Separate the witness's foundation, applicable schedule and calculation from any medical-necessity opinion. Here the insurer supported the excess-charge defense but did not prove the separate necessity defense.
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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.
