The chiropractor rate

Under New York’s no-fault insurance system, medical providers are reimbursed for services according to the workers’ compensation fee schedule. A longstanding dispute in no-fault litigation has centered on which fee schedule rate applies when a chiropractor performs acupuncture — should the provider be paid at the higher rate afforded to licensed acupuncturists, or at the lower chiropractor rate? The Appellate Term, Second Department, addressed this question directly in S.O.V. Acupuncture, P.C. v Global Liberty Ins. Co. of N.Y., reinforcing the principle that the provider’s licensure category — not the nature of the service rendered — controls the applicable reimbursement rate.

This issue has significant financial implications for chiropractic practices that incorporate acupuncture into their treatment protocols. Where a licensed acupuncturist might be reimbursed at one rate for CPT codes such as 97810 and 97811, a chiropractor performing the same procedure is limited to the lower chiropractor fee schedule rate. The Great Wall Acupuncture line of cases, which S.O.V. Acupuncture follows, has consistently held that licensure status governs reimbursement, creating a two-tiered payment structure for identical services.

Case Background

V. , as assignee of Angel DeJesus, brought suit against Global Liberty Insurance Company to recover first-party no-fault benefits. Global Liberty moved for summary judgment on multiple grounds: the assignor’s failure to appear for independent medical examinations (IMEs), late submission of one claim beyond the 45-day filing window, and overpayment based on application of the chiropractor fee schedule rate. The Civil Court, Kings County, denied the motion in its entirety. Global Liberty appealed.

The Appellate Term modified the order substantially, granting summary judgment on the IME no-show, the late-filed claim, and the fee schedule issues — while leaving intact only the claims where the insurer conceded liability.

Jason Tenenbaum’s Analysis

S.O.V. Acupuncture, P.C. v Global Liberty Ins. Co. of N.Y., 2020 NY Slip Op 51004(U)(App. Term 2d Dept. 2020)

Well in a few weeks and to the extent people still treat for motor vehicle accidents, this will be placed in the New York no-fault relic garbage can.

“With respect to the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover the unpaid portion of plaintiff’s claims which were denied on the ground that the amount sought exceeded the amount permitted by the workers’ compensation fee schedule, defendant established that it had fully paid plaintiff for the services billed under CPT codes 97810, 97811, 99202, and 99212 in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 ). Likewise, defendant demonstrated that it had fully paid plaintiff for the services billed under CPT codes 97026, except for the services rendered on December 11, 2015, March 1, 2016, March 17, 2016 and March 28, 2016, in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see id.). Thus, defendant established its prima facie entitlement to summary judgment upon the unpaid portion of those claims.”

Legal Significance

This decision is noteworthy for several reasons beyond the fee schedule holding. First, the Appellate Term reversed the Civil Court on three independent grounds — IME non-appearance, late claim submission, and fee schedule limitations — illustrating how a single no-fault action can involve overlapping defenses that compound to eliminate most or all of the plaintiff’s claims. Second, the court’s treatment of the IME mailing issue is instructive: the plaintiff argued that the scheduling letters were sent to the wrong address, but the court found that the address matched the one the assignor provided on the sworn NF-2 application.

This forecloses a common tactic of challenging IME notices based on address discrepancies where the claimant’s own sworn application supports the insurer’s mailing. Third, the decision reinforces the durability of the Great Wall Acupuncture precedent regarding chiropractor reimbursement rates, demonstrating that the Second Department continues to apply this rule without deviation.

Practical Implications

For providers billing acupuncture services performed by chiropractors, this decision confirms that there is no path around the lower reimbursement rate in the Second Department. Chiropractic practices that bill acupuncture CPT codes must account for the fee schedule differential in their financial planning. For insurers, the case provides a roadmap for structuring a multi-ground summary judgment motion: combining IME non-appearance, late filing, and fee schedule defenses can effectively dismantle a complaint across all claims.

Practitioners on both sides should also note the court’s emphasis on the NF-2 application as the controlling document for determining proper mailing addresses — a point that arises in countless no-fault disputes.

Key Takeaway: When a chiropractor performs acupuncture, reimbursement under New York’s no-fault fee schedule is limited to the chiropractor rate, not the licensed acupuncturist rate. The provider’s licensure category — not the nature of the service — determines the applicable fee schedule, a rule consistently upheld across the Second Department.

Related Articles

• NY Acupuncture Prima Facie Defense: Chiropractor Rate Limitations Upheld
• NY Acupuncture Fee Schedules: Licensed Practitioners Limited to Chiropractor Rates
• Understanding Medical Billing and Down-Coding in New York No-Fault Insurance Claims
• Fee Schedule Defense Requirements in No-Fault Insurance Cases
• New York No-Fault Insurance Law