When a no-fault statute gives the carrier an option to write in terms, we end up with messes. The Gecko did this in the within case. Under Florida’s statute, payment is limited to 80% of 200% of Medicare Part B of the year the service is rendered (2007 is the base fee year). Certain Medicare ground rules are applicable to limit the rate of payment, most usually applied int he MRI context. The open question is what happens when a provider bills an amount less than 80% of 200% of the Medicare amount?
Geico was cute and said it is always 80% of what is billed. And heck, they beat a class action when the 11th Circuit reversed a Southern District Judge’s decision holding, what we knew was the law, that if the billing is less than 80% of 200%, then the carrier pays the amount billed.
“The 4th DCA (Broward and Palm Beach County – think Mara Lago and Cops in Fort Lauderdale) agreed with the vacated Southey District Federal Judge’s holding. (“For instance, if a provider submits a bill for $100 and the amount allowed under the Schedule for that service is $150, the insurer could reimburse the provider $120 (80 percent of the amount allowed under the Schedule) or $100 (the Lesser Charge).”). Therefore, Geico’s argument that the statute requires coinsurance to apply to all billed amounts is clearly erroneous as the statute merely provides that an insurer may opt to limit reimbursement to the typical 80% reimbursement rate”
I liked the footnote: “Additionally, while Geico did not agree with the trial court’s ultimate holding, it “agreed on the language in the proposed Final Judgment.” In other words, we make no determination as to what the result would have been had Geico contested billed amounts under the 200% of the statutory fee schedule but above the 80% reimbursement rate.”
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