Healthcare Reimbursment can be costly: Pill bottle with money

Fourth District Court of Appeal Rules that PIP Healthcare Providers Might be Reimbursed at Rates Higher than Medicare Rates

Important news for healthcare providers that provide services to people claiming Personal Injury Protection benefits: you could get reimbursed at rates higher than the standard rates set by Medicare. In an opinion issued by the Fourth District Court of Appeal today in Northwest Center for Integrated Medicine v. State Farm Mutual Automobile Insurance Co.the 4DCA held that GIECO General Insurance Co. v. Virtual Imaging, 141 So. 3d  147 (Fla. 2013), left unresolved the question of whether the Medicare reimbursement rates for healthcare providers will always be a reasonable calculation for reimbursement.

Virtual Imaging had dealt with whether an insurance policy had to specifically state PIP benefits would be reimbursed at the Medicare reimbursement rate in order to reimburse at the Medicare rates. The Supreme Court held that the policy needed to specifically put the policy holder on notice that they were exercising their option to reimburse healthcare providers at the Medicare rates in order to be effective. Today’s decision deals with whether the Medicare rates can be determinative of a reasonable reimbursement rate, the other way of calculating how healthcare coverage is reimbursed under PIP. The Fourth District held that Virtual Imaging was not dispositive on this issue, and remanded the case to the trial court to make a merits finding on how exactly the Medicare reimbursement rates factor into a determination of reasonableness.

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