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David M. Barshay

Generally speaking, and with certain exceptions, the No-Fault Insurance reimbursement rates for medical claims are contained in the Workers’ Compensation Fee Schedule. See Ins. Law §5108 (“The charges for services … shall not exceed the charges permissible under the schedules prepared and established by the chairman of the workers’ compensation board … The superintendent [of the Department of Financial Services], after consulting with the chairman of the workers’ compensation board and the commissioner of health, shall promulgate rules and regulations implementing and coordinating the provisions of this article and the workers’ compensation law with respect to charges for the professional health services … No provider of health services … may demand or request any payment in addition to the charges authorized pursuant to this section.”). See also 11 NYCRR 68.1 (“(a) The existing fee schedules prepared and established by the chair of the Workers’ Compensation Board for industrial accidents are hereby adopted by the Superintendent of Financial Services with appropriate modification so as to adapt such schedules for use pursuant to the provisions of Insurance Law 5108”).

The Workers’ Compensation Fee Schedule is divided into sections based on general categories of services, such as Evaluation & Management, Radiology, Physical Medicine, Surgery, General Medicine, etc. These sections, however, are “for structural purposes only” and are not intended to limit the type of service a licensed medical practitioner can perform and bill. Additionally: “If a fee schedule has been adopted for a licensed health provider, the fee for services provided shall be the fee adopted or established for that licensed health provider …” 11 NYCRR 68.1(b)(3). There are Fee Schedules for chiropractors, podiatrists, dentists and psychologists. Services contained in the Worker’s Compensation Fee Schedule are identified by CPT (current procedural terminology) codes. Where a particular service is contained in the Workers’ Compensation Fee Schedule, the permissible charge is calculated by multiplying the relative value for that service by the applicable conversion factor. There are separate conversion factors based on type of service (Example: medicine, evaluation and management, physical medicine, self-employed physical and occupational therapists, surgery, radiology). The amount for each conversion factor, in turn, varies based on the geographical region in the State where the service was performed. In addition to such relative values and conversion factors: “The general instructions and ground rules in the workers’ compensation fee schedules apply [to no-fault insurance claims], but those rules that refer to workers’ compensation claim forms, pre-authorization approval and dispute resolution guidelines do not apply, unless specified in this Part.” 11 NYCRR 68.1(b)(1).

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