Not every no-fault bill is correct. New York's fee schedule is dense, and inflated billing — wrong conversion factor, stacked modifiers, unbundled CPT codes, missing DME invoices — is common. For carriers, third-party administrators, and defense counsel, a disciplined fee-schedule defense recovers real money on almost every file.
Start with the right ground rule
New York no-fault adopts the Workers' Compensation medical fee schedule by reference (11 NYCRR 68). Every defense begins by pulling the exact ground rule for the CPT code billed — radiology, surgery, physical medicine, and E&M each have different rules, and the wrong ground rule is the most common provider error.
Confirm the regional conversion factor matches the provider's actual location of service, not their billing address. NYC, Long Island, and upstate factors differ; using the wrong one inflates the bill on every line.
NCCI edits and unbundling
Providers frequently bill component codes separately when CMS National Correct Coding Initiative (NCCI) edits require them bundled. Run every multi-line bill through the NCCI table for the date of service and deny the bundled codes by citation, not opinion.
Multiple-procedure reductions also apply: the second-highest-valued procedure on the same date typically reimburses at 50%, the third at 25%. Many providers bill each at 100% and hope no one checks.
Modifier abuse
Watch for modifier -22 (increased procedural service), -59 (distinct procedural service), and -25 (significant separately identifiable E&M). Each requires specific supporting documentation. When the documentation isn't in the file, the modifier is improper and the line reduces to the base rate.
Bilateral modifier -50 should pay at 150% of the unilateral rate, not 200%. This is one of the highest-dollar overbilling patterns on surgical and injection codes.
DME and 'by report' codes
Durable medical equipment reimburses at 150% of the documented invoice cost or the Medicaid rate, whichever is lower. When a provider bills DME without attaching the invoice, issue a verification request for the invoice — and if it doesn't come back, deny on lack of documentation under the regulation.
'By report' codes (no listed schedule value) require a provider narrative justifying the value. Without one, there's no basis to pay above the lowest comparable code; reduce accordingly.
Time-based codes and documentation
Physical therapy, manual therapy, and therapeutic exercise codes are billed in 15-minute units under the CMS 8-minute rule. Charts that show 30 minutes total but bill four units fail the rule — only two units are reimbursable.
Same logic for prolonged service E&M codes: without contemporaneous time documentation, the prolonged-service add-on is denied and the visit reduces to the base E&M level supported by the chart.
Building the defense file
Every fee-schedule denial should issue on Form NF-10 within 30 days, citing the specific regulation section, the ground rule, and the math. 'Reduced per fee schedule' without detail is the weakest possible denial — arbitrators routinely overturn it.
When the dispute goes to AAA, the defense brief should attach the ground rule, the NCCI table, the conversion factor table, and a line-by-line recalculation. Arbitrators rule on the regulation; the side that shows the math wins.
Frequently Asked Questions
What is the best defense against inflated no-fault bills in NY?
A line-by-line recalculation against the Workers' Comp fee schedule (11 NYCRR 68): correct CPT ground rule, correct regional conversion factor, NCCI bundling, multiple-procedure reductions, modifier documentation, and DME invoice verification. Cite the section on every reduction in the NF-10.
Can a carrier deny a no-fault bill for missing DME invoice?
Yes — if the carrier first issues a timely verification request for the invoice. Reimbursement is capped at 150% of documented invoice cost or the Medicaid rate; without the invoice, there is no basis to calculate the payable amount.
How does the multiple-procedure reduction work in NY no-fault?
The highest-valued procedure on the same date of service pays at 100% of the fee schedule, the second at 50%, the third and beyond at 25%. Providers frequently bill each at 100%, creating a clean reduction opportunity.
Need expert help on your case?
Defending against inflated no-fault bills? We build fee-schedule defense packages — ground rules, NCCI edits, modifier audits, DME verification — that hold up at AAA arbitration.
Request Consultation