Treat Across the State Line, But NY Sets the Dime!

By: Leonardo Lampret, Associate Attorney

When a claimant suffers a work-related injury in New York but seeks treatment from an out-of-state provider, does New York’s Workers’ Compensation Fee Schedule govern the reimbursement rates? The Third Department addressed this issue in Bowman v. J & J Log & Lumber Corp., 305 A.D.2d 888, 758 N.Y.S.2d 852 (2003), providing guidance on how the Workers’ Compensation Board applies New York’s fee schedule to out-of-state providers.

Key Takeaways from Bowman

1. Claimants Can Seek Out-of-State Treatment: A claimant residing near a state border may reasonably seek treatment in a neighboring state.
2. Reimbursement Under NY’s Fee Schedule: While treatment is allowed, reimbursement is generally limited to New York’s Workers’ Compensation Fee Schedule.
3. Board’s Authority to Establish Fees: The Board has the authority to regulate fees for out-of-state treatment, ensuring claimants receive necessary care without excessive costs.
4. Economic and Humanitarian Objectives: Applying New York’s fee schedule aligns with the Workers’ Compensation Law’s goal of balancing claimant care with cost control (Matter of Smith v. Tompkins County Courthouse, 60 N.Y.2d 939, 941, 471 N.Y.S.2d 46, 459 N.E.2d 155 [1983]).

Supporting Case Law

• Employer: PCI International Inc (WCB# G202 0897; July 29, 2021): The claimant lived in Newark, NJ. The Board ruled that a claimant injured in New York and living near the state border falls under the same standard of care for reasonable fees of treatment per NYS fee schedule. The claimant would not be made to have a hardship if were confined to being treated in NYS.
• Employer: Magellan Concrete Structures (WCB# G240 6190; February 14, 2020): Similarly, the claimant was a New Jersey resident who got injured in New York. The Board required a New Jersey-based provider to adhere to New York’s fee schedule when treating a claimant who lived and worked in New York.

What If a Claimant Moves Out of State?

Generally speaking, the Board has found that out of state providers treating out of state claimants are paid at rates customary to the area in which the medical services are provided rather than the New York Fee Schedule. In Employer: Distron (WCB# 2791 6536; June w6, 2013), the Board found that claimants who move out of state (like Florida) may inform their new medical providers that they can request payment at the prevailing local rates—not necessarily under New York’s fee schedule.

Implications for Employers and Carriers

• If the claimant resides in New York or neighboring states: Out-of-state providers most likely will have to adhere to New York’s fee schedule. Carriers can dispute excessive charges.
• If the claimant (permanently) relocates further away: Providers may bill at prevailing local rates, reducing the carrier’s control over reimbursement costs.

Conclusion

New York’s fee schedule will most likely  apply to out-of-state providers treating claimants who still reside in New York or in neighboring states. However, once a claimant relocates permanently further away, the out-of-state provider most likely can request reimbursement based on local rates.