Reasonableness of Charges: A Florida PIP Decision With Lessons for New York Lien-Based Medical Cases

Key Takeaways

• In Florida PIP litigation, the reasonableness of a medical charge is a contested, provable fact — unlike first-party New York no-fault, where the fee schedule fixes the price.
• The Third District’s State Farm v M & E Diagnostic opinion shows the kind of expert foundation used to address reasonableness: community rates, fee schedules across coverage types, and the provider’s actual accepted reimbursements.
• The issue is far from academic in New York: in third-party cases where the patient treats on a lien, the value of the billed services must be proven, not assumed.
• The expert recitation quoted below is a usable template for building (or attacking) a charge-reasonableness opinion.

When a personal injury case includes boardable medical expenses, someone has to prove what the treatment was worth. New York practitioners are spoiled on the first-party side — the fee schedule answers by regulation — but outside its reach, a charge’s reasonableness becomes live, contested, and hard to prove. This Florida decision shows how the issue gets litigated where it is contested daily.

The Decision

STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, vs M & E DIAGNOSTIC SERVICES, INC., etc., 3D20-1193 (Fla 3d DCA 2021)

When trying a boardable medical case, a really thorny issue becomes what is the value of the services billed. NY generally does not get into that issue because no-fault has a fee schedule, thereby obviating the issue on the first-party case. But how about on the third-party case where the patient solely treats on a lien? Yes, this is rare in NY save some surgery cases. But here is something of relevance, at least to me:

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“Dr. Dauer attested that he has personal knowledge and expertise regarding the range and rate of charges for medical care in the relevant community, including the range and rate of charges for radiological services
provided in the area to patients by credentialed and experienced diagnostic centers and hospitals. Dr.

Dauer considered the reimbursement levels an charges in the community, his own charges in the community, various federal and state medical fee schedules applicable to motor vehicles and other
insurance coverages including worker’s compensation, Medicare, HMO/PPO, and other third-party insurance carriers, and the payments and reimbursements that M & E accepts from all sources. Dr. Dauer attested to conducting numerous peer reviews and obtaining extensive personal knowledge and professional expertise regarding medical care and medical charges and medical reimbursements in the Miami-Dade and Broward
communities. Dr.

The Legal Framework: Why New York Rarely Litigates Reasonableness — Until It Does

On a first-party New York no-fault claim, the price of treatment is set by the workers’ compensation fee schedules adopted into the no-fault regulation. A provider charges what the schedule allows; a carrier asserting an overcharge raises a fee schedule defense keyed to the published rates. There is no jury question about what an MRI is “worth” — the regulation answers it.

The third-party bodily injury case is different. When a plaintiff boards medical expenses — past treatment paid outside no-fault, or future care — the recoverable amount is the reasonable value of the services. Where the patient treated entirely on a lien, with no carrier payment and no fee schedule anchor, the billed amount is just a number on an invoice. Defense counsel can and should contest it; plaintiff’s counsel has to prove it.

What the Florida Expert Foundation Teaches

Florida’s PIP statute reimburses reasonable charges, so its courts have spent years refining what a reasonableness opinion looks like. The recitation from Dr. Dauer quoted above is a checklist of the data sources a charge-valuation expert draws on:

• Community rates — what comparable credentialed providers in the same geographic market charge for the same services.
• Cross-coverage fee schedules — workers’ compensation, Medicare, HMO/PPO and other third-party payor rates, used as benchmarks for the market value of the service.
• The provider’s own acceptance history — what the billing provider actually accepts as payment from all sources, which is often dramatically lower than the face amount of the bill.
• Professional experience — peer review work and personal familiarity with charges and reimbursements in the relevant communities.

For a New York lawyer building or attacking a reasonable-value case, that structure transfers directly. A plaintiff’s expert who can speak to community rates and the provider’s actual reimbursement experience presents a defensible number. A defendant who cross-examines on the gap between billed charges and amounts the provider routinely accepts can deflate an inflated lien.

Why This Matters on Long Island and in NYC Practice

Lien-based treatment tends to cluster in cases where no-fault benefits exhaust or coverage is unavailable — serious surgical cases chief among them. In those cases the medical specials often drive settlement value, so a credible methodology for valuing the charges matters to both sides of the caption. Carriers and defense counsel should not reflexively accept billed amounts in a car accident case; plaintiffs’ counsel should anticipate the challenge and have the foundation ready rather than relying on the invoice alone.

Practice Pointers

• Plaintiffs: If your client treats on a lien, retain a valuation-capable expert early and gather the provider’s reimbursement data. The bill alone will not survive a serious challenge.
• Defendants: Demand discovery on what the lien provider accepts from insured patients and other payors; the delta between billed and accepted is your cross-examination.
• Both sides: Fee schedules — workers’ compensation, Medicare, the no-fault schedule itself — are persuasive benchmarks of market value even where they do not legally control.
• Watch the foundation. The opinion must rest on identified, professionally reliable data; a conclusory “the charges are reasonable” gets nowhere.

Related Resources

• Fee schedule defense in no-fault insurance — the firm’s cluster hub on fee schedule litigation
• The firm’s Legal Encyclopedia
• Personal Injury practice
• New York No-Fault Insurance Law
• The CPLR 3212(g) paradigm
• Understanding IME No-Shows in New York No-Fault Insurance: Rights, Consequences, and Strategic Considerations
• Happy Mother’s Day
• The amendments to the regulations and what they mean to you.

Frequently Asked Questions

Why doesn’t New York litigate the reasonableness of medical charges in no-fault cases?

Because the no-fault regulation adopts fee schedules that fix the maximum reimbursable amount for each service. The “price” of treatment on a first-party claim is set by regulation, so disputes take the form of a fee schedule defense rather than a battle over reasonable value.

When does the reasonable value of medical bills become an issue in a New York injury case?

Primarily in third-party bodily injury cases where the plaintiff boards medical expenses that no fee schedule controls — most often when the patient treated on a lien, as can happen in surgical cases after no-fault benefits exhaust. There, the plaintiff must prove the reasonable value of the services, and the defense may contest it.

How does an expert prove medical charges are reasonable?

The expert ties the opinion to community rates for comparable providers, benchmark fee schedules (workers’ compensation, Medicare, HMO/PPO), the billing provider’s own accepted reimbursements, and professional experience with charges in the relevant market.