Key Takeaway
NY court case on healthcare provider's right to recover reasonable value for medical services when insurance claims are improperly processed or denied.
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.
Spanakos v Racanelli, 2021 NY Slip Op 50127(U)(App. Term 2d Dept. 2021)
(1) “Plaintiff, a chiropractor, brought this action to recover, among other things, the balance allegedly due him for healthcare services rendered to defendant. At a nonjury trial, plaintiff proffered evidence that he had submitted bills to defendant’s health plan requesting payment, which bills set forth a total charge of $ 1,756.81, which sum includes a co-payment of $ 480 due from defendant. Defendant presented evidence that plaintiff had failed to provide information necessary for the health plan to process plaintiff’s claim, but implicitly conceded that defendant was responsible for paying the $ 480 co-payment. After the trial, the Civil Court awarded plaintiff the principal sum of $ 480. [*2] Plaintiff appeals on the ground of inadequacy.”
(2) “It is well settled that a healthcare provider is entitled to recover for professional services rendered by him or her under an implied agreement by the patient to pay the reasonable value of the services (see Taranto v Abohwo, 45 Misc 3d 130, 3 N.Y.S.3d 287, 2014 NY Slip Op 51578 ; Brookhaven Mem. Hosp. Med. Ctr. v Lukashevskiy, 43 Misc 3d 128, 990 N.Y.S.2d 436, 2011 NY Slip Op 52557 ; Brottman v Crane, 11 Misc 3d 129, 815 N.Y.S.2d 493, 2006 NY Slip Op 50299 ). The performance and acceptance of such services give rise to the inference of an implied contract to pay for the reasonable value of the services (see Moors v Hall, 143 AD2d 336, 338, 532 N.Y.S.2d 412 ; Brookhaven Mem. Hosp. Med. Ctr. v Lukashevskiy, 43 Misc 3d 128, 990 N.Y.S.2d 436, 2011 NY Slip Op 52557; Long Is. Jewish Med. Ctr. v Budhu, 20 Misc 3d 131, 867 N.Y.S.2d 17, 2008 NY Slip Op 51436 ; Brottman v Crane, 11 Misc 3d 129, 815 N.Y.S.2d 493, 2006 NY Slip Op 50299).”
(3) “The terms of an agreement, if any, by plaintiff to seek recovery of his fees from defendant’s [*3] health plan is not part of the record. Assuming, without deciding, that plaintiff’s right to recover payment from defendant was not affected by plaintiff’s failure, if any, to properly pursue payment from defendant’s health plan, plaintiff, in any event, did not establish the reasonable value of the services he rendered, which proof is part of plaintiff’s prima facie case (see Castro v East End Plastic, Reconstructive & Hand Surgery, P.C., 47 AD3d 608, 610, 850 N.Y.S.2d 483 ). The sole proof submitted by plaintiff as to the reasonableness of the charges appearing on his bills was the bills themselves (see id.). Consequently, plaintiff failed to establish that the award in his favor was inadequate.”
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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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Jun 30, 2016Common Questions
Frequently Asked Questions
What is the no-fault fee schedule?
New York's no-fault fee schedule, established by the Workers' Compensation Board and the Department of Financial Services, sets the maximum reimbursement rates that no-fault insurers must pay for medical services. When an insurer pays less than the billed amount, citing the fee schedule as a defense, the provider can challenge the reduction by demonstrating that the fee schedule was improperly applied or that the services are not subject to fee schedule limitations.
Can a medical provider charge more than the fee schedule allows?
Medical providers treating no-fault patients are generally limited to the amounts set by the fee schedule and cannot balance-bill the patient for the difference. However, certain services may not be covered by the fee schedule, and disputes about whether a specific service falls within the fee schedule are common in no-fault litigation. The Department of Financial Services periodically updates the fee schedule rates.
How are fee schedule disputes resolved in no-fault arbitration?
When an insurer partially pays a claim citing the fee schedule, the provider can challenge the reduction through no-fault arbitration. The provider must demonstrate that the service billed is not subject to the fee schedule or that the fee schedule was incorrectly applied. The insurer bears the burden of proving the fee schedule applies and the correct rate was used. Fee schedule disputes often involve coding issues, modifier usage, and applicability of Workers' Compensation rates.
Does the no-fault fee schedule apply to all medical services?
Not all medical services are subject to the no-fault fee schedule. Certain services, supplies, and procedures may fall outside its scope, in which case the provider may bill the usual and customary rate. Disputes about whether a specific service or billing code is covered by the fee schedule are common. The Workers' Compensation Board fee schedule and the Department of Financial Services ground rules guide which services are covered and at what rates.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
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.
