Why Trust This Analysis
This article is part of our ongoing no-fault coverage, with 271 published articles analyzing no-fault issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
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. If you’re dealing with a no-fault insurance defense matter, an experienced attorney can help protect your rights.
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:
Free Consultation · No Fee Unless We Win
Does this apply to your situation?
Every case is different. Get a free, confidential case review from an experienced attorney who can tell you exactly where you stand.
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.
Related Articles
- New York No-Fault Insurance Law
- Understanding IME No-Shows in New York No-Fault Insurance: Rights, Consequences, and Strategic Considerations
- No-Fault regulatory amendments and their implications
- No-Fault verification requirements and partial compliance issues
- CPLR 3212(a) timing rules for summary judgment motions in New York
Legal Context
Why This Matters for Your Case
New York's no-fault insurance system, established under Insurance Law Article 51, is one of the most complex insurance frameworks in the country. Every motorist must carry Personal Injury Protection coverage that pays medical expenses and lost wages regardless of fault, up to $50,000 per person.
But insurers routinely deny valid claims using peer reviews, EUO scheduling tactics, fee schedule reductions, and coverage defenses. The Law Office of Jason Tenenbaum has handled over 100,000 no-fault cases since 2002 — from initial claim submissions through arbitration before the American Arbitration Association, trials in Civil Court and Supreme Court, and appeals to the Appellate Term and Appellate Division. Jason Tenenbaum is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
His 2,353+ published legal articles on no-fault practice are cited by attorneys throughout New York. Whether you are dealing with a medical necessity denial, an EUO no-show defense, a fee schedule dispute, or a coverage question, this article provides the kind of detailed case-law analysis that helps practitioners and claimants understand exactly where the law stands.
About This Topic
New York No-Fault Insurance Law
New York's no-fault insurance system requires every driver to carry Personal Injury Protection (PIP) coverage that pays medical expenses and lost wages regardless of who caused the accident. But insurers routinely deny, delay, and underpay valid claims — using peer reviews, IME no-shows, and fee schedule defenses to avoid paying providers and injured claimants. Attorney Jason Tenenbaum has litigated thousands of no-fault arbitrations and court cases since 2002.
271 published articles in No-Fault
Keep Reading
More No-Fault Analysis
Car Accident Recorded Statement in New York: Should You Give One?
The at-fault driver's adjuster wants a recorded statement within days of a New York car accident — and that call is designed to weaken your case.
Apr 5, 2026
Who Pays Car Accident Medical Bills in New York? A Step-by-Step Guide
New York no-fault PIP, primary health insurance, Medicaid/Medicare, and litigation liens — the full payment ladder for car-accident medical bills.
Apr 5, 2026
Former Judge Michael Ciaffa Has Been Located: From the District Court Bench to Private Practice
Former Judge Michael Ciaffa, whose District Court rulings shaped account stated and no-fault practice, resurfaces in private criminal defense practice.
Sep 19, 2016
BUMP – Now whoever said no-fault lawyers are not versatile…
Long Island no-fault lawyer successfully appeals family court child support case pro bono, demonstrating versatility beyond insurance law practice.
May 8, 2011
Fla 35-day timely submission
Florida's 35-day billing submission rule compared to NY's 45-day requirement - appellate court ruling against providers and strategic considerations for attorneys.
Jul 30, 2022
“Equitable estoppel” – Domotor light
Florida court affirms equitable estoppel doctrine when insurer wrongly denied PIP coverage then changed tactics after discovering their error in no-fault case.
Jun 22, 2021Was this article helpful?
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a no-fault matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
