OPPS stands for Outpatient Prospective Payment System.
It is a Medicare reimbursement methodology used to pay for hospital outpatient services. Instead of paying based strictly on a physician’s fee schedule, OPPS assigns services to payment classifications and reimburses based on predetermined rates.
In simple terms:
OPPS is one of Medicare’s official payment systems — and in certain situations, it produces a higher reimbursement amount than the standard non-facility “limiting charge.”
That difference matters in Florida PIP cases.
Why OPPS Comes Up in PIP Disputes
Under Florida’s Personal Injury Protection statute (§ 627.736(5)(a)), insurers that elect to limit reimbursement to the Medicare fee schedule must pay:
80% of 200% of the applicable Medicare fee schedule
The word “applicable” is critical.
In 2012, the Legislature removed the phrase “participating physician” from the statute and replaced it with “applicable fee schedule.” Courts have interpreted that change to mean insurers must use the highest applicable 2007 Medicare schedule, not simply default to the lower limiting charge.
That includes OPPS if it is the highest schedule.
The Broward County Decision on OPPS
In Conforti Chiropractic & Wellness Center v. State Farm (Broward County, April 25, 2022), the court addressed whether the insurer should have paid the higher 2007 OPPS amount instead of the lower limiting charge.
The court held that:
- The statute requires comparison between the Medicare schedule in effect at the time of service and the highest applicable 2007 schedule
- If OPPS is higher, it must be used
- Courts cannot rewrite the statute to insert limiting language that the Legislature removed
The ruling makes clear: if OPPS produces the highest applicable 2007 reimbursement, it governs.
Common Insurance Company Arguments — And Why They Fail
1: “OPPS is not a fee schedule — it’s a payment system.”
Courts have rejected this technical distinction. If the policy elects Medicare coding and payment methodologies, OPPS falls within that framework.
2: “The provider wouldn’t qualify for Medicare reimbursement under OPPS.”
Florida’s PIP statute expressly states that reimbursement is required for services lawfully provided within the provider’s license — regardless of whether Medicare would reimburse that provider directly.
Medicare eligibility is not the test. The PIP statute controls.
3: “We only intended to use the limiting charge.”
The Legislature removed “participating physician” and replaced it with “applicable schedule.” Under rules of statutory construction, courts presume that amendment changed the meaning.
If lawmakers intended insurers to pay only the limiting charge, they would have said so.
They didn’t.
The Practical Rule for PIP Reimbursement
When an insurer elects the Medicare fee schedule limitation:
- Identify the Medicare schedule in effect on the date of service
- Compare it to the highest applicable 2007 Medicare schedule
- Use the higher amount
- Apply 80%
If OPPS is the highest applicable 2007 amount, it must be used.
Why This Matters for Providers and Litigators
If you are reviewing an Explanation of Benefits and see reimbursement based solely on the non-facility limiting charge:
- Check the 2007 OPPS rate
- Compare it to the limiting charge
- Determine whether OPPS is higher
- Evaluate whether there was an underpayment
This issue frequently arises with imaging and radiology CPT codes.
Disclaimer
This post is provided for informational and educational purposes only and does not constitute legal advice. The analysis reflects general interpretations of Florida PIP law and selected court decisions as of the date of publication. Laws, case authority, and policy language may change. Each claim involves unique facts and contractual provisions that may alter the outcome. Readers should consult qualified legal counsel regarding specific matters before relying on this information.
