News & Updates

Blog

OIR Provides Guidance on PIP Fee Schedule

OIR Provides Guidance on PIP Fee Schedule

Published on: | Insurance

The Florida Office of Insurance Regulation (OIR) issued Informational Memorandum OIR-12-02M earlier this month providing guidance to insurers and they implement new Personal Injury Protection reforms.  The Informational Memorandum coincided with Governor Scott’s signing HB 119 into law.

The Informational Memorandum points out that one of the new provisions of the PIP reform requires insurers to provide notice of the schedule of medical charges or “fee schedule” to insureds if the insurer is limiting reimbursement.  The Office of Insurance Regulation has developed sample endorsement language, which is set forth below and its contained in an attachment to the Informational Memorandum.

Insurers are not required to use the sample language.  The OIR has committed to review insurers’ filings on an expedited basis as long as they make stand-alone filings for the endorsement.

SAMPLE FEE SCHEDULE ENDORSEMENT

 Use of Medical Fee Schedule for Personal Injury Protection Claims

 [The insurer] will limit reimbursement of medical expenses to 80 percent of a properly billed reasonable charge, but in no event will [the insurer] pay more than 80 percent of the following schedule of maximum charges:

  1. For emergency transport and treatment by providers licensed under Chapter 401, Florida Statutes, 200 percent of Medicare.
  2. For emergency services and care provided by a hospital licensed under Chapter 395, Florida Statutes, 75 percent of the hospital’s usual and customary charges.
  3. For emergency services and care as defined by s. 395.002(9), Florida Statutes,  provided in a facility licensed under Chapter 395, Florida Statutes,  rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community.
  4. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services.
  5. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.
  6. For all other medical services, supplies, and care, 200 percent of the allowable amount under the participating physicians schedule of Medicare Part B. However, if such services, supplies, or care is not reimbursable under Medicare Part B, [the insurer] will limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation, as determined under s. 440.13, Florida Statutes,  and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided. Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation will not be reimbursed by [the insurer].

For purposes of the above, 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 was rendered and for the area in which such services were rendered, except that it will not be less than the allowable amount under the participating physicians schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.