Acupuncture Fee Schedule in No-Fault: Payment at the Chiropractor Rate Upheld

Key Takeaways

• In Mind & Body Acupuncture v State Farm, the carrier won summary judgment by proving it had fully paid the acupuncture bills at the workers’ compensation fee schedule rate for acupuncture performed by chiropractors.
• The suit sought only the difference between the provider’s charges and the fee-schedule payments — and the provider raised no triable issue in opposition.
• The decision follows the S.O.V. Acupuncture and Master Cheng line from the Appellate Term, while the Second Department’s Acupuncture Now “it depends” approach is relegated to a cf. citation.
• Proof of full payment at the chiropractor rate, properly documented, remains a complete defense to acupuncture balance billing in the Second Department’s lower courts.

Acupuncture billing has generated a disproportionate share of no-fault fee schedule litigation in New York. The reason is structural: when these disputes began, the workers’ compensation fee schedules — which no-fault payments incorporate — contained no rate written specifically for licensed acupuncturists. Carriers responded by reimbursing acupuncture at the rate payable to chiropractors performing the same service, and providers sued for the difference. This Appellate Term decision shows where that fight has settled.

The Decision

Mind & Body Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 2022 NY Slip Op 50603(U)(App. Term 2d Dept. 2022)

“In support of its motion, defendant made a prima facie showing of its entitlement to summary judgment dismissing the complaint by demonstrating that it had fully paid plaintiff for the acupuncture services at issue in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see S.O.V. Acupuncture, P.C. v Global Liberty Ins. Co. of NY, 68 Misc 3d 132, 2020 NY Slip Op 51004 ) and that the subject claims sought the difference between the amount plaintiff charged for the services rendered and the payments made. In opposition, plaintiff failed to demonstrate the existence of a triable issue of fact (see Master Cheng Acupuncture, P.C. v Global Liberty Ins. of NY, 69 Misc 3d 143, 2020 NY Slip Op 51371 ; S.O.V. Acupuncture, P.C. v Global Liberty Ins. Co. of NY, 2020 NY Slip Op 51004; cf. Global Liberty Ins. Co. of NY v Acupuncture Now, P.C., 178 AD3d 512 ).”

Three citations to a defunct insurance carrier. Two stand for the chiropractor fee schedule proposition, one stands for “it depends”. The one where “it depends” is quickly c.f.’d…

The Legal Framework

New York’s no-fault regulation caps a provider’s recovery at the charges permitted by the workers’ compensation fee schedules. Insurance Law § 5108 and 11 NYCRR 68 incorporate those schedules wholesale; a provider may not collect more from the carrier (or balance-bill the patient) beyond the scheduled amount. The mechanics of proving and defending these caps are collected in the firm’s fee schedule defense hub.

For acupuncture, the historical gap in the schedules forced an analogy. Carriers and, ultimately, the courts looked to the rate for the same CPT-coded acupuncture services when rendered by chiropractors — the licensed profession whose scheduled rates were the closest fit. The Appellate Term’s S.O.V. Acupuncture and Master Cheng decisions blessed that approach, and Mind & Body applies it without hesitation.

The cf. to Global Liberty v Acupuncture Now is the interesting note. There, the Second Department signaled that the right rate may depend on the record — that “it depends” on what proof is adduced about the appropriate schedule. As the commentary above observes, the Appellate Term cited it and moved on. In practice, a carrier that documents full payment at the chiropractor rate, and a provider that offers nothing concrete in response, will see the complaint dismissed.

Note also what the carrier proved here: not just the rate, but full payment and that the claims sought only the difference. That framing matters — the dispute was purely about pricing, with no medical necessity or verification issues muddying the motion.

Why This Matters

For carriers, the playbook is stable: pay acupuncture claims at the chiropractor fee schedule rate, document the payments line by line, and support the summary judgment motion with a certified coder’s or claims professional’s affidavit tying each CPT code to the schedule. A fee schedule defense for post-April 2013 services need not even be preserved in the denial.

For acupuncture providers, balance-billing litigation over the chiropractor-rate differential is now an uphill claim in the Second Department’s lower courts. Opposition needs substance — an expert affidavit identifying a different applicable rate or a coding error — because conclusory objections do not create a triable issue of fact.

For patients, the fee schedule is protective: providers who accept no-fault assignments cannot pursue the patient for the difference between their charge and the scheduled rate.

Practice Pointers

1. Match the proof to the defense. A fee schedule motion rises or falls on the payment documentation and the affidavit explaining the rate applied.
2. Providers: attack the coding, not the concept. The chiropractor-rate analogy is settled at the Appellate Term; viable opposition disputes the specific code, units, or arithmetic.
3. Watch the procedural posture. Acupuncture Now shows the Appellate Division may tolerate more nuance in a declaratory judgment record than the Appellate Term does on a Civil Court summary judgment motion.
4. Plead partial payment precisely. Where the carrier paid at the reduced rate, the complaint should be framed (and answered) as a differential dispute — it narrows discovery and the trial to a pure fee schedule question.

Frequently Asked Questions

How much does no-fault insurance pay for acupuncture in New York?

No-fault reimburses acupuncture under the workers’ compensation fee schedules. Where the schedules lacked a rate specific to licensed acupuncturists, courts approved payment at the rate for the same services performed by chiropractors — the rule applied in Mind & Body v State Farm.

Can an acupuncturist sue for the difference between the billed amount and what the insurer paid?

The provider can sue, but if the insurer proves it fully paid at the chiropractor workers’ compensation rate, Appellate Term precedent supports summary judgment dismissing the claim unless the provider raises a genuine fact issue about the applicable rate or coding.

Can a no-fault patient be billed for acupuncture charges above the fee schedule?

No. Providers treating no-fault patients are limited to the fee schedule amounts and may not balance-bill the patient for the difference.

Related Resources

• Fee schedule defense in New York no-fault — the firm’s fee schedule cluster hub
• The firm’s Legal Encyclopedia
• No-Fault defense practice
• Understanding CPLR 3212(g) summary judgment paradigm
• Critical timing rules for summary judgment motions under CPLR 3212(a)
• No-fault verification requirements and compliance standards
• Reasonable excuse defenses in no-fault insurance cases
• New York No-Fault Insurance Law