Fee schedule is not precluded/ New Jersey FS discussion

Understanding Cross-Border Medical Fee Schedules: New York vs. New Jersey

When personal injury victims seek medical treatment across state lines, complex questions arise about which fee schedules apply and how insurance companies must handle reimbursement. A recent New York appellate decision provides crucial guidance for both healthcare providers and accident victims navigating these cross-border billing issues.

The Excel Surgery Center Decision: Key Principles Established

The case of Excel Surgery Ctr., LLC v Metropolitan Prop. & Cas. Ins. Co., 2019 NY Slip Op 51843(U) (App. Term 2d Dept. 2019), addressed critical issues that frequently arise when New York accident victims receive treatment from out-of-state medical providers.

The court’s decision clarified two essential principles that affect personal injury cases throughout Nassau County, Suffolk County, and the greater New York area:

1. Fee Schedule Defense Preservation Under 11 NYCRR 65-3.8(g)(1)(ii)

The court held that insurance companies can preserve their fee schedule defense without timely denial for services rendered after April 1, 2013. As the decision explained:

“11 NYCRR 65-3.8 (g) (1) (ii), effective April 1, 2013, 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.’”

2. New Jersey Fee Schedule Application

Perhaps most significantly, the court found that “the coder’s affidavit was sufficient to establish, prima facie, that defendant had fully paid the claim submitted by the New Jersey provider in accordance with the New Jersey medical fee schedule.”

The Significance of Cross-Border Medical Treatment

For personal injury victims in the New York metropolitan area, cross-border medical treatment is common. Residents of Nassau and Suffolk Counties frequently seek specialized care in Manhattan, New Jersey, or Connecticut. Understanding how fee schedules apply in these situations is crucial for protecting your rights and ensuring proper compensation.

Common Cross-Border Treatment Scenarios

Personal injury victims often cross state lines for medical treatment in cases involving:

• Motor vehicle accidents occurring near state borders
• Specialized surgical procedures not available locally
• Emergency treatment while traveling
• Second opinion consultations with specialists
• Rehabilitation and long-term care facilities
• Workers traveling for business who are injured out-of-state

Understanding Fee Schedule Defense Timing Requirements

The Excel Surgery decision represents a significant evolution in New York’s approach to fee schedule defenses. Prior to the 2013 regulatory changes, insurance companies had to timely deny claims to preserve their fee schedule defenses. The current regulations provide different protections.

The April 1, 2013 Regulatory Change

The amendment to 11 NYCRR 65-3.8(g)(1)(ii) fundamentally changed the landscape for fee schedule disputes. Under the current regulation, insurance companies can assert fee schedule defenses for services rendered after April 1, 2013, regardless of whether they timely denied the original claim.

This change affects how personal injury attorneys must approach no-fault cases and slip and fall claims involving medical billing disputes. The timing of medical services can determine which legal standards apply.

Services Before vs. After April 1, 2013

The distinction between services provided before and after April 1, 2013, creates different legal obligations:

Services Before April 1, 2013:

• Traditional timely denial requirements apply
• Insurance companies must establish timely mailing of denials
• Failure to timely deny may preclude fee schedule defense
• Higher burden on insurance companies to prove compliance

Services After April 1, 2013:

• Fee schedule defense automatically preserved
• No requirement for timely denial to assert fee schedule
• Broader protection for insurance companies
• Greater burden on providers to prove entitlement to higher fees

New Jersey Fee Schedule Application in New York Cases

One of the most interesting aspects of the Excel Surgery decision involves the application of New Jersey’s medical fee schedule to a New York no-fault claim. This cross-jurisdictional issue frequently arises in the tri-state area.

Regulatory Framework for Out-of-State Providers

New York regulation 11 NYCRR 68.6(b) and (c) governs how out-of-state medical providers should be reimbursed under New York’s no-fault system. The regulation generally provides that out-of-state providers should be paid according to the fee schedule of the state where services were provided, subject to certain limitations.

Why Out-of-State Fee Schedules Matter

The application of different state fee schedules can significantly impact claim values:

• Different states have varying reimbursement rates
• Some procedures may be covered differently across state lines
• Geographic variations in medical costs affect fee schedules
• Regulatory differences can impact billing practices

Practical Implications for Personal Injury Victims

Understanding cross-border fee schedule issues helps accident victims make informed decisions about their medical care and legal options.

Choosing Medical Providers

When considering out-of-state treatment, personal injury victims should understand:

• How their no-fault insurance will handle reimbursement
• Which fee schedule will apply to their treatment
• Potential out-of-pocket costs for cross-border care
• Documentation requirements for out-of-state providers

Impact on Settlement Negotiations

Cross-border medical treatment can affect settlement negotiations in several ways:

• Different fee schedules may result in lower or higher medical expenses
• Insurance companies may challenge out-of-state billing more aggressively
• Additional documentation may be required to support claims
• Jurisdictional issues may complicate dispute resolution

Strategic Considerations for Healthcare Providers

Medical providers treating New York accident victims must understand the fee schedule implications of their location and the timing of services.

Documentation Requirements

The Excel Surgery decision emphasized the importance of proper documentation. The court found that “the coder’s affidavit was sufficient” to establish prima facie evidence of proper payment. This highlights the need for:

• Detailed coding documentation
• Clear identification of applicable fee schedules
• Proper affidavit preparation by qualified medical coders
• Comprehensive billing record maintenance

Billing Best Practices for Cross-Border Providers

Out-of-state providers treating New York patients should:

• Verify coverage requirements before treatment
• Understand applicable fee schedule limitations
• Maintain detailed treatment documentation
• Work with qualified medical coders familiar with multi-state regulations
• Establish relationships with New York personal injury attorneys

Legal Strategy Implications for Personal Injury Attorneys

The Excel Surgery decision affects how personal injury attorneys approach cases involving cross-border medical treatment.

Case Evaluation Considerations

When evaluating cases with out-of-state medical treatment, attorneys should consider:

• The timing of medical services relative to April 1, 2013
• Which state’s fee schedule applies to each provider
• Potential challenges to cross-border billing
• Documentation quality from out-of-state providers

Litigation Strategy

Cross-border cases may require different litigation approaches:

• Expert testimony on out-of-state fee schedules
• Careful attention to regulatory compliance
• Coordination with providers in multiple jurisdictions
• Understanding of interstate commerce implications

The Role of Medical Coders in Cross-Border Cases

The Excel Surgery decision specifically referenced the importance of medical coder testimony in cross-jurisdictional cases. Certified medical coders play crucial roles in:

Multi-State Fee Schedule Analysis

• Understanding different state regulations
• Proper application of various fee schedules
• Documentation of compliance efforts
• Expert testimony in billing disputes

Insurance Company Defenses and Cross-Border Claims

Insurance companies often challenge cross-border medical billing more aggressively than in-state claims. Common defense strategies include:

Fee Schedule Challenges

• Arguing for lower out-of-state fee schedules
• Questioning necessity of out-of-state treatment
• Challenging billing code applications
• Requiring additional documentation for out-of-state providers

Procedural Challenges

• Jurisdictional disputes over applicable law
• Venue challenges for litigation
• Service of process complications
• Discovery issues across state lines

Future Trends in Cross-Border Medical Billing

Several trends are shaping the future of cross-border medical billing in personal injury cases:

Technology Integration

• Electronic health records facilitating multi-state treatment
• Automated billing systems reducing geographic barriers
• Telemedicine expanding cross-border consultation options
• Digital verification systems streamlining out-of-state claims

Regulatory Harmonization

• Interstate compacts for medical licensing
• Standardized billing practices across states
• Coordinated no-fault insurance regulations
• Uniform documentation requirements

Frequently Asked Questions

Can New York accident victims be treated by out-of-state medical providers?

Yes, New York accident victims can receive treatment from out-of-state providers. The no-fault insurance system generally covers such treatment, but different fee schedules may apply depending on where the services are provided.

Which fee schedule applies when a New York resident receives treatment in New Jersey?

Generally, the fee schedule of the state where treatment is provided applies. In the Excel Surgery case, the court recognized that New Jersey providers should be paid according to New Jersey’s fee schedule, subject to New York’s regulatory framework.

Do insurance companies have to timely deny out-of-state medical claims?

For services provided after April 1, 2013, insurance companies can assert fee schedule defenses without timely denial under 11 NYCRR 65-3.8(g)(1)(ii). However, other denial grounds may still require timely action.

What documentation is required for cross-border medical billing?

Cross-border medical billing typically requires the same documentation as in-state billing, but may need additional verification of the applicable fee schedule and compliance with multi-state regulations. Medical coder affidavits can be particularly important.

How do cross-border treatments affect personal injury settlements?

Cross-border treatments can affect settlements by changing the applicable medical expenses, potentially requiring different expert testimony, and creating additional billing complexities that may need to be addressed in negotiations.

Protecting Your Rights in Cross-Border Personal Injury Cases

Cross-border medical treatment adds complexity to personal injury cases, but understanding the applicable rules can help protect your rights and ensure proper compensation. Whether you’re receiving treatment from construction accident injuries or other personal injury claims, the location of your medical care can significantly impact your case.

The Excel Surgery decision provides important guidance for navigating these complex issues, but each case presents unique challenges requiring experienced legal representation. Understanding fee schedule applications, timing requirements, and documentation needs is essential for successful claim resolution.

Call 516-750-0595 for a free consultation with experienced New York personal injury attorneys who understand the complexities of cross-border medical billing and can help ensure you receive full compensation regardless of where you receive treatment.

Legal Update (February 2026): Since this 2019 post, New York’s no-fault fee schedule regulations under 11 NYCRR 65-3 have undergone multiple amendments, including updates to section 65-3.8 regarding fee schedule defenses and reimbursement procedures. The cross-border billing principles and preservation of fee schedule defenses discussed may be subject to revised regulatory frameworks. Practitioners should verify current provisions of 11 NYCRR 65-3.8 and related sections for the most up-to-date requirements.

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