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Family Physician
Family Physician, Internet Researcher
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I am looking where I can get printed documentation to the guidelines

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I am looking where I can get printed documentation to the guidelines for billing medical claims in the state of florida for PIP. We are have problems with the actual billed amount and the pts portion once the carrier has paid. We are tryting to establish the guidelines and the allowable. We know how to bill the issue is the legal fee schedule that is to be determined.
If you can please clarify your abbreviation "PIP"?

You said that you are having problems? What specific problems have you been having?
Customer: replied 6 years ago.
Auto Carriers(Auto Accidents)and Personal Injury Cases(i.e.Slip and Fall,etc). The attorneys handling the cases are stating we must charge the carriers a set Florida regulated Fee schedule of which I can not find. My concern is if we are regulated by this fee schedule that I can not find,then how can they (Att.'s ) then ask for an additional reductions to settle the case once the carriers have paid. If that reduction is requested and we approve to give an additional reduction how is this not discrimination if not given to all cases?If we are a provider with example BC and we waive a patients copayments and it is not a hardship case that would be considered discrimination and we would be in violation of the contract that the physician. Would that not be any different with auto and /or WC cases? Thank you in advance for your answer to this question.
I believe that this is the relevant statute:
http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=627.736&URL=CH0627/Sec736.HTM

The portion that seems to answer your question is as follows;

2. The insurer may limit reimbursement to 80 percent of the following schedule of maximum charges:

a. For emergency transport and treatment by providers licensed under chapter 401, 200 percent of Medicare.

b. For emergency services and care provided by a hospital licensed under chapter 395, 75 percent of the hospital's usual and customary charges.

c. For emergency services and care as defined by s. 395.002(9) provided in a facility licensed under chapter 395 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.

d. 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.

e. 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.

f. 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 may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers' compensation, as determined under s. 440.13 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 is not required to be reimbursed by the insurer.

3. For purposes of subparagraph 2., 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 may 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.

4. Subparagraph 2. does not allow the insurer to apply any limitation on the number of treatments or other utilization limits that apply under Medicare or workers' compensation. An insurer that applies the allowable payment limitations of subparagraph 2. must reimburse a provider who lawfully provided care or treatment under the scope of his or her license, regardless of whether such provider would be entitled to reimbursement under Medicare due to restrictions or limitations on the types or discipline of health care providers who may be reimbursed for particular procedures or procedure codes.

5. If an insurer limits payment as authorized by subparagraph 2., 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.



I would however suggest contacting the Florida Medical Association OR the state Insurance Department for a specific clarification if this does not seem to answer your question OR if this does not appear to match the payments you are receiving.
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