For most providers outside of an emergency hospital setting, PIP insurers are allowed to limit reimbursement to 80% of 200% of the Medicare allowable charges. If the CPT code that the provider is billing for is not contained in the Medicare Fee Schedule, then the provider has to bill under the Florida Workers Compensation Fee Schedule set forth at Florida Statutes Section 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care are provided. Services, supplies, or care that are not reimbursable under Medicare or workers’ compensation are not required to be reimbursed by the insurance company.
The “applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect at the time the services, supplies, or care were rendered and fo the area in which such services were rendered, except that it may not be less than the applicable 2007 Medicare Part B fee schedule for medical services, supplies, and care subject to Medicare Part B. “
There is no limitation on the number of treatments or other utilization limits that apply under Medicare or workers’ compensation.
If the PIP insurer limits payments under Medicare or the Workers’ Compensation Fee schedule, “the person providing such services, supplies, or care may not bill or attempt to collect from the insured any amount in excess of such limits, except for amounts that are not covered by the insured’s personal injury protection coverage due to the coinsurance amount or maximum policy limits.”
There are three different Medicare Fee Schedule (Participating, Non-Participating and Not Limiting). The statute does not specify which column providers should use to calculate the Medicare allowable. It is unclear which coloumn should be used. “Not Limiting” is the highest, and “Participating” is the lowest. In the past, when MRI’s were placed on the Medicare Fee Schedule, court’s ruled that payment was limited to the Participating rate.