Key Takeaway
New York court ruling highlights insurance carriers must properly authenticate documents when denying physical therapy claims under fee schedule limits.
Understanding Fee Schedule Denials in No-Fault Insurance Claims
Physical therapy providers frequently encounter denials from insurance carriers claiming that submitted fees exceed the allowable amounts under New York’s workers’ compensation fee schedule. However, as demonstrated in a recent appellate court decision, carriers cannot simply assert these defenses without proper legal foundation. The case highlights a critical procedural requirement that often trips up insurance companies attempting to limit New York No-Fault Insurance Law payments.
When carriers deny claims based on per diem unit exhaustion—particularly the common 8-unit (now 12-unit) denials—they must do more than attach documents to their motion papers. The court’s analysis reveals how procedural missteps can undermine otherwise valid fee schedule defenses, creating opportunities for healthcare providers to recover appropriate compensation for their services.
Jason Tenenbaum’s Analysis:
NL Quality Med., P.C. v GEICO Ins. Co., 2020 NY Slip Op 51340(U)(App. Term 2d Dept. 2020)
“With respect to the second cause of action, defendant failed to establish, as a matter of law, its defense that the fees charged exceeded the amounts set forth in the workers’ compensation fee schedule (see Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132, 2009 NY Slip Op 50732 ), because, among other things, defendant attempted to rely on certain documents which were attached to defendant’s motion papers without authentication, foundation or even discussion (see Liberty Chiropractic, P.C. v 21st Century Ins. Co., 53 Misc 3d 133, 2016 NY Slip Op 51409 ).”
This is the line the court uses when it is an 8 unit (now 12 unit) denial based upon exhaustion of per diem units. The court expects the carrier to authenticate someone else’s records.
Key Takeaway
Insurance carriers cannot successfully defend fee schedule violations by simply attaching unverified documents to their legal papers. Courts require proper authentication, foundation, and substantive discussion of evidence when carriers attempt to prove that physical therapy fees exceed allowable amounts under the workers’ compensation fee schedule framework.
Related Articles
- [Fee schedule defense procedural requirements](/ 2010/03/fee-schedule-defense-no-fault-insurance-long-island-nyc/)
- Competent evidence standards for fee schedule defenses
- Medical billing and down-coding practices in no-fault claims
- Acupuncture provider rate limitations under fee schedules
- New York No-Fault Insurance Law
