Unlike prior PIP statutes that applied the “usual and customary” standard to determine allowable charges for medical services, Florida’s 2008 version (627.736), mostly mandates that allowable charges are 200% of prospective payments for the same services under Medicare Parts A & B. (Main exceptions: emergency transportation and emergency hospital services.)
For the most part, the Medicare tie-in reduces the amounts payable to medical providers, and because the PIP statute also explicity prohibits medical providers from balance billing beyond the 20% remaining after PIP’s 80% payment of allowable charges (627.736(5)(a)5.), the Plaintiff’s (patient) out-of-pocket medical expenses are likewise reduced. No longer may a medical provider seek full reimbursement from the patient for charges unpaid after the receipt of PIP payments. Doing so under the 2008 PIP statute is an actionable offense.
Accordingly, for motor vehicle accident attorneys and bodily injury adusters, the calculation of out-of-pocket medical expenses in small to medium-sized claims is as simple as 1, 2, 3. Out-of-pocket expenses are 20% of allowable charges, a determination made from reviewing the PIP Log or Explanation of Benefits documents,
(Matters become more complicated where the Plaintiff has sustained an income loss and/or PIP has exhausted without covering all allowable medical charges.)
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Jeffrey P. Gale, P.A. is a South Florida based law firm committed to the judicial system and to representing and obtaining justice for individuals – the poor, the injured, the forgotten, the voiceless, the defenseless and the damned, and to protecting the rights of such people from corporate and government oppression. We do not represent government, corporations or large business interests.