80% of 200% of Medicare Part B

Understanding PIP Fee Schedule Calculations: The 80% of 200% Medicare Dilemma

Personal Injury Protection (PIP) insurance operates under complex fee schedules that determine how much insurers must pay healthcare providers. A recent Florida appellate decision highlights a particularly intricate scenario involving Medicare Part B calculations that has significant implications for both insurers and medical providers.

The case involves the intersection of percentage-based fee schedules and actual billed amounts, creating a mathematical puzzle that can dramatically affect payment obligations. When fee schedules reference “80% of 200% of Medicare Part B” rates, but the actual bill falls below that threshold, insurers face strategic decisions about payment methods that can have lasting financial consequences.

This type of fee schedule complexity is not unique to Florida — similar issues arise in New York No-Fault Insurance Law cases, where understanding the nuances of payment calculations can make the difference between proper reimbursement and costly litigation.

Jason Tenenbaum’s Analysis:

GEICO GENERAL INSURANCE COMPANY vs HALLANDALE BEACH ORTHOPEDICS, INC. A/A/O FRITZNIE JARBATH, 4D21-206 (Fla 4th DCA 2021)

If a fee schedule says that you are only liable for 80% of 200% of a fee and the billed amount is less than 80% of 200% of the fee, what can you do?

The Florida court said In Muransky, we held that “under the PIP statute, if the billed amounts are less than 80% of the fee schedule, the insurer may pay the billed amounts in full or pay the 80% reimbursement rate of maximum charges.”

In Muansky, the carrier paid 80% of the billed amount and got burned. Here, the Court remanded for findings as to the proper fee schedule. Play with this on certain bills and ground rules… It is messy 🙂

Key Takeaway

The Florida Fourth District Court of Appeal confirmed that insurers have options when billed amounts fall below fee schedule thresholds. They can either pay the full billed amount or apply the 80% reimbursement rate to maximum allowable charges. However, choosing the wrong payment method can lead to significant financial exposure, as demonstrated by the carrier’s experience in the referenced Muransky case.

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