Background

Under the No-Fault Law, an individual that has no-fault coverage is entitled to payment for necessary medical expenses incurred as a result of a motor vehicle accident.  Section 65-3.16 of the No-Fault Law prescribes that payment of benefits shall be “in accordance with fee schedules” promulgated by the Superintendent of Financial Services. The promulgated fee schedules serve as a means of controlling costs associated with treatment, and assist in the making and processing of claims for no-fault benefits.

Through Insurance Law Section 5108, the No-Fault Law adopted fee schedules previously established by the Workers’ Compensation Board.  It also authorized the Superintendent of Insurance to create new schedules for services not established by the Workers’ Compensation Board.

Workers’ Compensation Medical Fee Schedule

The New York State Workers’ Compensation Medical Fee Schedule (“Fee Schedule”) consists of seven sections:

  1. Evaluation and Management

  2. Anesthesia

  3. Surgery

  4. Radiology

  5. Pathology and Laboratory

  6. Medicine

  7. Physical Medicine

The Fee Schedule book also contains separate schedules for psychology, chiropractic, and podiatry.

Each service or procedure has an assigned CPT (“Current Procedural Terminology”) code.  The CPT codes in each section fall in consecutive numerical ranges. Bills submitted to no-fault carriers must identify the correct CPT codes for the treatment rendered and charge only the authorized, scheduled fee.

The respective fee schedule provides a “unit value” or “relative value” for described services.  It also provides a “conversion factor” for each of four geographic regions, which is essentially a money amount determined according to the zip code of the provider.  

The permissible charge for a specific treatment is determined by multiplying the relative value for the service by the conversation factor.

Fee Schedules for Services Not Established by the Workers’ Compensation Board

11 N.Y.C.R.R. Section 68.2(a) authorizes the Superintendent of Insurance to establish fee schedules for professional health services covered by No-Fault for which schedules have not been prepared and established by the Workers’ Compensation Board. These fee schedules are found in Appendix 17-C and establish fees for various dental, social work, therapy, optometric, and thermographic services.

Non-Fee Scheduled Services

If a professional health service reimbursable under the No-Fault Law is not set forth in any fee schedule (either in the Workers’ Compensation Fee Schedule or in Appendix 17-C), the healthcare provider must bill according to one of the prescribed methods:

  • If a fee schedule exists that is applicable to the provider, then the provider shall establish a fee or unit value consistent with other fees, or unit values for comparable procedures shown in such schedule, subject to review by the insurer.

For example, if a physician performs a service for which there is no assigned code, the proper charge for such service is determined by using the applicable physician’s fee schedule to find a code for a procedure that is most similar to the service performed.   

  • If the Superintendent has not adopted or established a fee schedule applicable to the provider, then the permissible charge for such service shall be the prevailing fee in the geographic location of the provider, subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the Superintendent.

For example, as there is no fee schedule for acupuncture, if an acupuncturist performs a service for which there is no assigned code, the acupuncturist can charge the market rate for such services.

Billing a No-Fault Patient Directly for Fees in Excess of the Fee Schedule

Insurance Law Section 5108(c) states that “[n]o provider of health services . . . may demand or request any payment in addition to the charges authorized pursuant to this section.”  Furthermore, “[e]very insurer shall report to the commissioner of health any patterns of overcharging, excessive treatment or other improper actions by a health provider.”

As such, billing of fees in excess of the fee schedule not only is impermissible, but should be directly reported to the Superintendent of Insurance.

Billing an Insurer in Excess of the Fee Schedule

In regard to dates of service prior to April 1, 2013, if an insurer did not assert a timely fee schedule defense for a provider’s charge in excess of the fee schedule, that defense could be deemed waived. The new amendments to the No-Fault Regulations, effective for services provided after April 1, 2013, allow insurers to submit a fee schedule defense at any time.

Medical Supplies

The insurance regulations governing medical equipment and supplies limit a provider’s recovery of medical equipment benefits to 150 percent of the cost.

A Note on Providing Medical Services Not Covered by Workers’ Compensation

Contrary to an often-raised but meritless insurer defense, medical services reimbursable under no-fault are not limited to services that are covered by workers’ compensation. As addressed, the no-fault law adopted the Workers’ Compensation Medical Fee Schedule as a means to set maximum charges for similar services, not to limit services reimbursable under Section 5102(a)(1) of the Insurance Law.  

We are specialists in no-fault billing and collection.  To learn more from us about the No-Fault Workers’ Compensation Medical Fee Schedule, please call (516) 427-5400 for an immediate, free consultation.  




[1] See Rogak’s New York No-Fault Law & Practice, 2009 Edition
[2] Power Acupuncture P.C. v State Farm Mut. Auto. Ins. Co., 2006 NY Slip Op 50393(U)(Civil Court, Kings Co.)
[3] See 11 N.Y.C.R.R. § 68.5