South Florida Hospital News
Monday August 19, 2019
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February 2008 - Volume 4 - Issue 8

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Legal Update: Be Aware of Florida’s Changes to PIP Reimbursements

The Florida Legislature recently enacted a new statute governing the reimbursement of personal injury protection (PIP) benefits effective January 1, 2008. This statute governs which providers may be reimbursed for medical services and the amount of reimbursement.

Pursuant to the new statute, physicians, hospitals and other health care providers will be paid at 80% of 200% of the 2007 Medicare fee schedule for services, other than emergency services. Emergency room charges will be paid at 75% of the hospital’s usual and customary charge, and emergency room services by physicians will be paid based on the usual and customary charge for such services. If the services or supplies are not reimbursed by Medicare, reimbursement from the insurer will be limited to 80% of the amount allowed under workers’ compensation. The remaining 20% must be collected from the patient. For those services that are not reimbursed by Medicare or workers’ compensation, the insurer will not be required pay any amount to the practitioner.

According to the new statute, reimbursement will only be provided for PIP services or care that are either: (1) provided, supervised, ordered or prescribed by a medical doctor, osteopathic physician, doctor of chiropractic medicine, or dentist licensed under Florida law (collectively referred to as "Licensed Physicians" or individually as "Licensed Physician"), or (2) provided by a licensed hospital or ambulatory surgical center, a licensed individual or entity providing emergency medical treatment, a licensed health care clinic that meets certain standards, or an entity wholly owned by certain licensed health care practitioners or hospitals.

The statute requires that a licensed health care clinic meet one of two possible standards. First, the statute will reimburse licensed health care clinics that are accredited by the Joint Commission on Accreditation of Healthcare Organizations, the American Osteopathic Association, the Commission on Accreditation of Rehabilitation Facilities, or the Accreditation Association for Ambulatory Health Care, Inc. In the alternative, the statute will reimburse licensed health care clinics that: (1) have a licensed medical doctor, (2) have been continuously licensed for more than three years or be a publicly traded corporation, and (3) provide at least four of the following specialties: general medicine, radiography, orthopedic medicine, physical medicine, physical therapy, physical rehabilitation, prescribing or dispensing outpatient prescription medication, or laboratory services.

Practitioners will be reimbursed for PIP services as long as one of the two requirements of the statute set forth above is satisfied. If services are ordered, prescribed or supervised by a Licensed Physician and performed by another health care provider, the services will be reimbursed. Similarly, facilities that do not meet the requirements of the new statute may provide and receive reimbursement for PIP benefits as long as services are provided, supervised, ordered or prescribed by a Licensed Physician. Thus, PIP services provided by health care providers other than Licensed Physicians and facilities that do not meet the requirements of the statute may still be eligible for PIP reimbursement if the services are provided, supervised, ordered or prescribed by Licensed Physicians.

Michele L. Martello is a health lawyer in the Fort Lauderdale office of Broad and Cassel. She can be reached at (954) 764-7060 or mmartello@broadandcassel.com.
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