Why this report
Most guides to medical liens are written for hospitals or for injured patients. Very little is written for outpatient practices: chiropractors, physical therapists, pain management, orthopedic and neurology practices, imaging centers and surgery centers. These practices treat a large share of personal injury patients and often wait months or years to be paid.
The question this report answers is simple: in each state, what protects an outpatient practice's bill when it treats an injured patient and waits for the case to settle?
Method
- Coverage. The 10 states with the largest personal injury caseloads (Edition 1). Each state was researched against the same nine questions: whether a statutory lien exists, how to perfect it, amount limits, contract liens and letters of protection, attorney duties, health insurance and balance billing, paid-vs-billed damages rules, recent changes, and what it means in practice.
- Sources. Statutes, court opinions and state bar ethics opinions. Secondary sources were used only to find primary ones.
- Only confirmed points are published. Anything we could not confirm in a primary source was left out of this report and the state pages.
- Cross-check. Statute text for each state was checked on November 12, 2026, on the official legislature site or the 2025 code. The most recent and highest-impact authorities were checked a second time:
- Cal. SB 623
- In re Ferguson (Ga. 2026)
- HonorHealth v. Abboud (Ariz. App. 2026)
- Murray v. Punina (N.J. 2026)
Seven findings
1. Only 4 of the 10 states give most outpatient providers a statutory lien
| Statutory lien for outpatient providers? | States |
|---|---|
| Yes, broad | Arizona (any licensed provider; charges over $250 for non-hospitals) and Illinois (Health Care Services Lien Act: physicians, PTs, surgery centers and more) |
| Yes, for some provider types | Georgia (physician and chiropractic practices; chiropractors added in 2023) and New Jersey (physicians and dentists; chiropractors and PTs not named) |
| Hospitals only (or very narrow physician coverage) | California, Nevada, New York, Texas (Texas also covers EMS and certain emergency or university physicians) |
| No lien statute found | Florida (hospital liens only by county ordinance) and Pennsylvania |
In the other six states, an outpatient practice depends on a signed lien agreement or a letter of protection (LOP). In no-fault and PIP states, it also depends on the auto insurer.
2. Where a lien statute exists, procedure decides whether the lien is valid
The statutes are strict, and a missed step usually voids the lien:
- Georgia: notice at least 15 days before filing, by first-class and certified mail, or by statutory overnight delivery. The verified statement is filed in two counties within 90 days of first treatment.
- Arizona: the lien must be recorded with the county recorder within 30 days of the first visit, and copies mailed within 5 days. Under HonorHealth v. Abboud (2026), the lien must state whether treatment has ended or is continuing, and listing dates of service isn't enough. A petition for review is pending in the Arizona Supreme Court.
- New Jersey: filed with the county clerk within 90 days of first treatment, and served within 10 days by registered mail or in person, or the lien is void.
- Illinois: no filing, but notice must reach the patient and the at-fault party before payment, or the lien can be defeated.
3. Caps and reductions are built into most lien laws
| State | Limit |
|---|---|
| Illinois | All medical liens together are capped at 40% of the gross recovery, split 20/20 between professionals and facilities, with pro-rata reduction |
| New Jersey | Physician liens are capped at 25% of the recovery |
| Arizona | One-third of the recovery is exempt, and a "fair and equitable" compromise is required (11 factors) |
| California (rideshare cases) | For Uber/Lyft accidents on or after Jan 1, 2027 (SB 623): recoverable charges are capped at the 70th percentile of FAIR Health, and the excess is void |
| Pennsylvania (car crashes) | Charges are capped at 110% of Medicare, even when paid from a liability settlement under an LOP |
| Florida (car crashes) | PIP fee schedule; no balance billing above it |
4. "Bill the health insurance first" is becoming a condition
- Georgia: the lien is unenforceable unless a claim was sent to each of the patient's health insurers and rejected.
- Arizona: a provider in the patient's insurance network can't assert a lien unless the network contract allows it or the patient signs a waiver.
- Texas: a provider that can bill the patient's plan must do so on time, or it loses that amount from the patient (CPRC ch. 146). In a case with an attorney, sending the bill to the patient's attorney by the first day of the 11th month after service satisfies the billing deadline (§146.002(c-1)).
- Illinois: the lien act doesn't require billing insurance. But an in-network "payment in full" contract can wipe out the lien (Turner, 2017).
5. Courts and lawmakers are opening up lien arrangements
Recent laws make the provider's arrangements more visible:
- Florida HB 837 (2023): the patient must disclose the LOP, the coded bills, any sale of the bill to a factoring company, and the referral source. Unpaid bills are valued at insurance rates or a Medicare/Medicaid multiple.
- Georgia SB 68 (2025): LOPs, itemized bills, factoring sales and referral source are "relevant and discoverable", and juries see both billed and insurance amounts.
- California SB 623 (2026, rideshare cases):
- lien sales must be disclosed within 30 days;
- bills must be itemized at the procedure-code level;
- the provider may have to declare, under penalty of perjury, how many patients a firm referred in the past 24 months;
- attorney referral fees and kickbacks are unlawful;
- a provider may not agree to reduce a lien before treating.
- Texas: a provider's negotiated rates can be discovered (K & L Auto Crushers, 2021).
Against that trend, Illinois and Arizona still allow the full reasonable billed amount as damages, and Nevada keeps a strict collateral-source rule.
The practical point: expect your bills, referral relationships and any lien sales to be examined. Charge consistently, code every line and record the referral source.
6. The attorney's duty to pay you is real, but conditional
In every state reviewed, a lawyer who knows about a valid lien or a signed LOP must protect those funds under the trust-account rules (Rule 1.15 or equivalent). But "valid" matters:
- In Georgia, In re Ferguson (2026) cleared an attorney who ignored a chiropractor's "Notice of Doctor's Lien" that he and his client had signed. He could reasonably treat it as an unperfected statutory lien.
- The lesson: use a clearly worded lien agreement or LOP signed by both patient and attorney. A document that only claims to be a statutory lien isn't enough.
7. In no-fault states, the auto insurer usually comes first
| State | Rule |
|---|---|
| New York | No-fault pays first, up to $50,000, at the workers' comp fee schedule. Providers usually work through an assignment of benefits. |
| New Jersey | PIP, or the health plan the patient chose as primary, at the fee schedule. No balance billing. Murray v. Punina (2026): future medical costs within PIP limits can't be presented at trial. |
| Pennsylvania | $5,000 in first-party auto benefits pays first. The 110% of Medicare cap follows the bill into the liability settlement. |
| Florida | PIP pays 80% of 200% of the Medicare Part B fee schedule, with no balance billing. |
For practices in these states, an LOP covers only what's left after the auto coverage, and often at fee-schedule rates.
10-state comparison
| Statutory lien for outpatient providers | Main authority | Perfection | Amount limits | Must bill health insurance | Paid vs. billed | Key change 2023–26 | |
|---|---|---|---|---|---|---|---|
| AZ | Yes (broad) | A.R.S. §§33-931–937 | Record ≤30 days; mail ≤5 days; state ended/continuing | ⅓ exempt; mandatory compromise | In-network: no lien without contract or waiver | Billed (reasonable) | Abboud (2026, under review) |
| CA | No (hospitals only) | Civ. Code §§3045.1–.6; §3333.9 | Contract; rideshare sale disclosed ≤30 days | Rideshare: 70th pct FAIR Health | No general rule | Paid if insured (Howell); uninsured lien patients prove value (Pebley) | SB 623 (2026) |
| FL | No | §768.0427; §627.736 | Contract / LOP | PIP fee schedule | No (but valued at insurer rates) | Paid; unpaid at insurer rate or Medicare/Medicaid multiple | HB 837 (2023) |
| GA | Physician and chiro practices | O.C.G.A. §§44-14-470–477 | 15-day notice; file in 2 counties ≤90 days | Reasonable charges | Yes, claim and rejection required | Jury sees billed + insurer amounts | SB 168 (2023); SB 68 (2025); Ferguson (2026) |
| IL | Yes (broad) | 770 ILCS 23 | Notice before payment | 40% total cap, pro rata | No (but in-network contracts can defeat the lien) | Billed (reasonable) | None found |
| NJ | Physicians and dentists | N.J.S.A. 2A:44-35–46 | File ≤90 days; serve ≤10 days | Physician ≤25% of recovery | Auto: PIP or chosen health plan | Collateral source deduction; PIP amounts excluded | Murray v. Punina (2026) |
| NV | No (hospitals only) | NRS 108.585–.660 | Contract / LOP | None found for contract liens | Hospitals only | Collateral source barred (Proctor) | Taylor v. Brill (2023) |
| NY | No (hospitals only) | Lien Law §189; Ins. Law art. 51 | Assignment of no-fault benefits or settlement | No-fault fee schedule | Auto: no-fault first | Post-verdict collateral-source reduction (CPLR 4545) | Litigation Funding Act (2025) |
| PA | No | 75 Pa.C.S. §§1711, 1719, 1797 | Contract / LOP | Auto: 110% of Medicare | Auto: first-party first | Paid accepted as full payment (Moorhead) | None enacted |
| TX | No (hospitals, EMS, narrow physician) | Prop. Code ch. 55; CPRC §41.0105, ch. 146 | Contract / LOP | Hospital: 50% of recovery | Partly (CPRC ch. 146) | Paid or incurred (Haygood) | Bills failed in 2025 |
Short summaries only. See each state file for the full analysis and sources.
What every outpatient practice should do (all 10 states)
- Know which tool your state gives you. A statutory lien (AZ, IL, GA, NJ for physicians) has strict filing and notice rules. Put the deadlines on a calendar at intake.
- **Get a written lien agreement or LOP signed by the patient and the attorney**, even where a statute exists. It's the backstop if the statutory steps fail.
- Check insurance at intake. In GA, AZ, TX and IL, the patient's health coverage can change or erase your lien rights. In NY, NJ, PA and FL, auto coverage comes first.
- Bill as if a jury will read it: consistent charges, a procedure code on every line, the referral source recorded, and any lien sale documented.
- Track the attorney on every case. Notice usually has to reach the current attorney before money is paid out, so a change of attorney can cost you the lien.
- Expect reductions, and plan for them. IL, NJ and AZ build reductions into the statute. Everywhere else they're negotiated, so set a written reduction policy.
Limitations
- No attorney review. This report was researched and written by Ambula. It has not been reviewed by a licensed attorney. It is general information, not legal advice.
- Ten states. Edition 1 covers 10 states. The other 40 are not covered yet.
- Negative findings. Where we say a state has no lien statute for outpatient providers, that means we found none in the state's code. A reader should confirm it for their situation.
- The law changes. HonorHealth v. Abboud is under review by the Arizona Supreme Court, and every state can amend its laws. Each page shows the date it was last verified.
- Corrections. If you find an error, tell us and we will correct it and note the change.
Disclosure
The author works at Ambula, which makes EMR and practice management software that includes lien tracking. The report recommends practices, not products. Ambula is not mentioned in the findings.