In a recent decision, the Florida Supreme Court actually strengthened the billed amount statute of FS §627.736(5)(a)(5) which states:
“An insurer may limit payment as authorized by this paragraph only if the insurance policy includes a notice at the time of issuance or renewal that the insurer may limit payment pursuant to the schedule of charges specified in this paragraph… If a provider submits a charge for an amount less than the amount allowed under subparagraph 1., the insurer may pay the amount of the charge submitted.” (Emphasis added)
This Florida Supreme Court opinion makes the billed amount doctrine alive and well
In simple terms, this statute means that if the medical provider submits a claim form billing an amount for a CPT code that is less than 80% of what the fee schedule would allow, then the insurance company is required to pay the full billed amount of the CPT code on a medical provider’s claim form without any reductions.
In the recent Florida Supreme Court case, aster rendering services to the patient, the medical provider submitted a HCFA with a CPT code charging $100.00. The 80% of the fee schedule under FS §627.736(5)(a) (1) for the CPT code charged was $149.92. So, 80% of the maximum charge under the fee schedule was $119.94 which was higher than the submitted $100.00 charge. Because the charge of $100.00 was less than $119.94, FS §627.736(5)(a)(5) expressly allowed the 16 insurance company to pay the $100.00 amount billed. Instead of paying the $100.00 amount billed, the insurance company chose to pay 80% of the amount billed which was $80.00.
The Florida Supreme Court allowed the insurance company to pay 80% of the $100.00 billed amount or $80.00 because the insurance company’s policy had specific language that allowed the insurance company to make that reduction. The Florida Supreme Court allowed insurance company to pay less than the billed amount if the insurance company’s policy specifically allowed it to: “pay 80% of a submitted charge if that charge is less than the amount reimbursable under the sched- ule or other statutory provisions, may the insurer pay 80% of the charge submitted by a medical provider.”
The good news is that this also means if the insurance policy does not have this specific language in it, then they would have to pay the billed amount under FS §627.736(5)(a)(5). This case is positive for medical providers because trial courts have used cases from the District Courts of Appeal to claims that the billed amount doctrine was gone for good. This Florida Supreme Court opinion makes the billed amount doctrine alive and well. I have not seen many insurance company policies with this specific language mentioned in the Florida Supreme Court opinion. So, it is important to review the insurance policy before determining whether the insurance company erred in not paying the billed amount.
George A. David, Esq.
