Florida PIP providers must pay close attention to how they bill medical services. Recent Florida Supreme Court case law confirms that billing below the Medicare fee schedule directly reduces what you get paid, even when the insurer has elected to use the statutory fee schedule.
The Florida Supreme Court decision in Allstate Insurance Company v. Revival Chiropractic LLC makes the rule clear:
If you bill less than the applicable Medicare fee schedule amount, the insurer may lawfully pay only eighty percent of what you billed, even if the fee schedule would have allowed a higher payment.
This article explains why this happens, how Florida law allows it, and what providers should do to avoid losing money.
The Key Rule Providers Must Understand
Under Florida Personal Injury Protection law:
- Insurers are required to reimburse eighty percent of reasonable medical expenses
- Insurers may elect to limit reimbursement using the statutory schedule of maximum charges
- The fee schedule operates as a ceiling and not a guaranteed minimum
The statute expressly allows this result:
If a provider submits a charge that is less than the amount allowed under the fee schedule, the insurer may pay the amount of the charge submitted.
The Florida Supreme Court confirmed that this language is permissive and not mandatory. An insurer may choose to pay the higher scheduled amount, but it is not required to do so. Instead, the insurer may pay eighty percent of the billed charge.
Practical Example CPT Code 99203 in Miami
Consider a common evaluation and management code.
CPT code 99203
Miami Medicare fee schedule amount 236.48
Eighty percent of the fee schedule 189.18
If you bill the fee schedule amount
Billed amount 236.48
Insurer payment 189.18
If you bill below the fee schedule
Billed amount 200.00
Insurer payment 160.00
The result is a loss of 29.18 for a single visit solely because the provider billed below the fee schedule. Florida law does not require the insurer to increase payment to match the fee schedule when the provider underbills.
What the Florida Supreme Court Confirmed
In Revival Chiropractic, the provider argued that once an insurer elected the fee schedule, it must either pay eighty percent of the fee schedule or one hundred percent of the billed amount if the bill was lower.
The Florida Supreme Court rejected that argument.
The Court held:
- The central requirement of the PIP statute is payment of eighty percent of reasonable expenses
- The fee schedule is an optional limitation and not a guaranteed payment floor
- Insurance policies may lawfully allow payment of eighty percent of the billed charge even when the schedule would allow more
In simple terms, the billed amount controls the payment calculation when it is lower than the fee schedule.
Why This Matters for Florida PIP Providers
Many providers mistakenly believe that electing the fee schedule guarantees payment at the scheduled amount. That belief is incorrect.
Billing below the fee schedule means:
- Your reimbursement is permanently capped at the lower amount
- The insurer is legally allowed to pay less
- You cannot later demand the higher fee schedule amount
The Florida Supreme Court made clear that there is no statutory floor that protects providers who underbill.
Best Practices for PIP Providers
To protect reimbursement and avoid unnecessary losses:
- Always bill at or above the applicable Medicare fee schedule
- Confirm the correct geographic locality before billing
- Remember that insurers pay eighty percent and not one hundred percent
- Do not assume the fee schedule will protect you from underbilling
Billing below the schedule does not reduce disputes. It reduces revenue.
Bottom Line
Florida law is clear. If a provider bills less than the Medicare fee schedule, the insurer may pay eighty percent of that lower amount even when the fee schedule would have allowed a higher payment.
For Florida PIP providers, the takeaway is simple.
Your bill sets the ceiling on your payment.
Billing below Medicare guarantees lower reimbursement.
Disclaimer: Educational content only. This article is not legal advice and is intended for general informational purposes for Florida PIP providers.
