Almost every no-fault payment in New York is governed by a fee schedule. If you bill above it, you get cut down. If the carrier pays below it, you're entitled to the difference plus interest and attorney fees. Knowing the schedule cold is the single highest-leverage skill in no-fault billing and arbitration.
Where the NY no-fault fee schedule comes from
New York no-fault adopts the New York Workers' Compensation medical fee schedule by reference (11 NYCRR 68). Each CPT code has a base relative value, multiplied by a conversion factor that varies by specialty and by region of the state (NYC, Long Island, and the rest of New York each have different multipliers).
For services with no Workers' Comp value — certain durable medical equipment, supplies, or newer codes — no-fault uses the Medicaid rate, the manufacturer's invoice plus a markup, or a usual-and-customary standard, depending on the category.
How to calculate a no-fault bill correctly
Start with the CPT code and the correct ground rule. Pull the relative value, apply the regional conversion factor for the provider's locality, and apply any modifiers (bilateral, multiple-procedure, assistant surgeon). For an MRI or CT, check the radiology ground rules — global vs. technical vs. professional component changes the math significantly.
Bill at the schedule amount, not above it. Billing above the schedule doesn't get you more money; it gives the carrier a clean reason to underpay and forces you to fight for what you were already entitled to.
The most common fee-schedule denials
Carriers reduce or deny bills citing: wrong region, wrong specialty conversion factor, incorrect modifier, bundling (NCCI edits), multiple-procedure reduction, missing documentation for time-based codes, and 'no fee schedule value' for newer or DME codes.
Most of these denials are winnable at arbitration when the rebuttal cites the specific ground rule and shows the math. Arbitrators decide fee-schedule disputes on the regulation, not on opinion.
DME, supplies, and 'by report' codes
Durable medical equipment under no-fault is reimbursed at 150% of the documented cost (invoice required) or the Medicaid rate, whichever is lower. Carriers routinely deny these without requesting the invoice, then point to the missing invoice as the basis for denial — a denial that doesn't survive arbitration when the invoice is produced in the filing.
'By report' codes (services with no listed value) require a narrative from the provider and supporting documentation. Submitted correctly the first time, they pay; submitted bare, they get denied for lack of documentation.
Why fee-schedule arguments win
Unlike medical necessity disputes — which hinge on dueling doctors — fee-schedule disputes are arithmetic. The arbitrator opens the regulation, applies the ground rule, and rules. When the claimant's filing already does the math and cites the section, the carrier has nowhere to hide.
That's why fee-schedule challenges have one of the highest claimant win rates in no-fault arbitration when the file is built correctly.
Frequently Asked Questions
What fee schedule does New York no-fault use?
New York no-fault uses the NY Workers' Compensation medical fee schedule (adopted by 11 NYCRR 68), with regional conversion factors. Codes without a Workers' Comp value default to Medicaid, invoice-plus-markup, or usual-and-customary depending on the service.
Can a provider bill above the no-fault fee schedule?
Technically a provider can submit a bill at any amount, but reimbursement is capped at the fee schedule amount. Billing above the schedule only invites reductions and disputes — there's no upside.
How is DME reimbursed under NY no-fault?
DME is reimbursed at 150% of the documented invoice cost or the Medicaid rate, whichever is lower. The invoice must be submitted with the bill or in response to a verification request.
Need expert help on your case?
Underpaid on the fee schedule? We rebuild bills against the regulation — correct ground rule, regional factor, modifiers, invoices — and recover the difference plus interest and statutory attorney fees.
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