Fee Schedule Defenses
Fee-schedule proof, coding disputes and the post-2013 excessive-fee rules. A preserved defense still needs evidence; the archive separates older rate decisions from later developments.
104 articles from 2008–2024 · 1 current · 48 reviewed case notes · by Jason Tenenbaum
Start here
The explainer for this topic. Read it first; the articles below go deeper on single issues.
Current articles
Articles the firm treats as current: published since 2024, or older and re-checked against today's law. Most recently published or reviewed first.
- Acupuncture Reimbursements and Insurance Legalities Explained Dec 11, 2024
Explore the Forrest Chen v. GEICO case and its impact on acupuncture insurance reimbursements in NY. Key insights for providers and patients.
How the firm handles these matters
Reviewed case notes by year
Notes on decisions from earlier years that the firm has re-read against current law. Each note states when it was last reviewed and what has changed since.
2021
2019
2018
2017
2016
2015
2014
2012
2011
2010
2009
- Fee Schedule Defenses in NY No-Fault Insurance: St. Vincent Med Care Case Analysis
- NY Acupuncture Prima Facie Defense: Chiropractor Rate Limitations Upheld
- NY Acupuncture Fee Schedules: Licensed Practitioners Limited to Chiropractor Rates
- The chiropractor rate is all that an acupuncurist is entitled to
Older archive
Case notes as they were written at the time. They have not been re-checked against later decisions, so treat them as history and confirm the current rule before relying on one.
2019 (2)
2018 (5)
- CPM – now it is up to DFS and WCB to address the problem
- Acupuncture Needle Reinsertion Billing in New York No-Fault: How Far Does the False-Billing Defense Reach?
- 8 units may apply to various specialties
- The 8-Unit Per Diem Rule: Workers Compensation Board Clarifies PT Billing Limits in NY No-Fault
- Fee Schedule/not precluded
2017 (9)
- Fee schedule defense not substantiated
- Fee schedule defense failed
- Court approves the chiro rate for Evaluation codes and consultation codes
- Acupuncture that is broken down by code
- No acupuncture fee schedule estoppel
- Functional ATIC/ medial necessity and fee schedule defense susbstantiated
- Hearsay insufficient to substantiate a fraud defense/Fee Schedule discussion
- A true prima facie showing on summary judgment motion
- Judicial Notice has it outter limits
2016 (4)
2015 (5)
2014 (5)
2013 (7)
- Medical necessity disputes in major medical disputes may be raised at any time
- More acupuncture from the First Department
- Acupuncture Fee Schedule in No-Fault Cases: First Department Endorses the Chiropractor Rate
- 8 units applies to billing medical providers only?
- Chiropractor fee schedule applies to all billed for codes
- The Constitutional Challenge to New York's No-Fault Acupuncture Fee Schedule
- It looks like someone did not include the fee schedule as an exhibit in their acupuncture motion
2012 (6)
- An interesting decision on a well known performer of enhanced MUA
- Denial and EOB is sufficient to preserve fee schedule defense
- The failure to affirmatively seek judicial notice of the fee schedule (again) proves fatal to a motion for summary judgment
- More MUA – this one is over the top
- Another motion to dismiss an initial acupuncture session is denied
- Surgical Center Does Not Need Article 28 Licensing for No-Fault Reimbursement in New York · superseded
2011 (5)
- Acupuncture – the fee schedule is incorporated by reference
- Nothing gives me a bigger headache than reading about acupuncture and the fee schedule
- Fee schedule defense not preserved abesent a timely denial
- How much was that anesthesia really worth?
- Only in no-fault can a Civil Court JHO "reverse" the holdings of the Appellate Divisions and the Court of Appeals
2010 (3)
Frequently asked questions
What is the no-fault fee schedule?*
The no-fault fee schedule sets the maximum charges a provider may bill for services covered by first-party benefits. Those charges shall not exceed the schedules prepared by the chair of the Workers' Compensation Board for industrial accidents, except where the insurer or arbitrator determines that unusual procedures or unique circumstances justify the excess charge (Insurance Law § 5108(a)). The superintendent adopted them for no-fault in 11 NYCRR Part 68 (11 NYCRR 65-3.16(a)(1); 11 NYCRR 68.1). Law changed April 1, 2013: for services rendered on or after that date, fees above the schedule are not proof of claim and are never payable (11 NYCRR 65-3.8(g)(1)(ii)); earlier services follow the prior rule.
Can a medical provider charge more than the fee schedule allows?
No. A provider of health services may not demand or request any payment in addition to the charges authorized by the fee schedule (Insurance Law § 5108(c)), so the patient cannot be balance-billed for the difference. Charges above the schedule are permitted only where the insurer or arbitrator determines that unusual procedures or unique circumstances justify them (Insurance Law § 5108(a)). For a service not listed in an applicable schedule, the provider sets a fee consistent with comparable procedures in that schedule, or, where no schedule applies to the provider, the prevailing fee in the provider's area (11 NYCRR 68.5). Out-of-state services follow 11 NYCRR 68.6.
How are fee schedule disputes resolved in no-fault arbitration?
The provider files for arbitration under Insurance Law § 5106(b) with the $40 fee (11 NYCRR 65-4.2(b)(1)(iii)), and the conciliation center first tries to settle the dispute (11 NYCRR 65-4.2(b)(2)). The arbitrator decides on written submissions or after a hearing and applies the Workers' Compensation Board schedules as adopted in 11 NYCRR Part 68, including their ground rules (11 NYCRR 68.1(b)). The usual questions are the correct code, unit values and modifiers, and whether an unlisted service was priced consistently with comparable procedures (11 NYCRR 68.5). A provider whose bill exceeded the schedule recovers no attorney's fee unless the dispute involved interpreting the schedule (11 NYCRR 65-4.6(h)).
Does the no-fault fee schedule apply to all medical services?
The schedule governs every health service that first-party benefits cover: charges for the services listed in Insurance Law § 5102(a)(1), and any further health service charges incurred as a result of the injury, may not exceed the Workers' Compensation Board schedules (Insurance Law § 5108(a); 11 NYCRR 68.1(b)). Where a covered service is not set forth in a schedule, the provider prices it consistently with comparable procedures in the applicable schedule, or, if no schedule applies to that type of provider, at the prevailing fee in the provider's area, subject to insurer review (11 NYCRR 68.5). Workers' compensation pre-authorization and time-limit rules do not apply to no-fault (11 NYCRR 68.1(b)).
* The law on this point has changed. The answer states the change, its effective date, and which claims the earlier rule still governs. Answers reviewed against the statutes and decisions in force as of September 2026.