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New Split Among DCAs As to Applicable Medicare Part B Reimbursement Rate—Participating Price versus Limiting Charge

In Progressive Select Insurance Company v. In House Diagnostic Services, Inc., a/a/o Darryl Frazier, No. 4D21-2581 (Fla. 4th DCA April 26, 2023), the Fourth District concluded that the proper reimbursement rate under the Florida PIP Statute—section 627.736(5)(a), Florida Statutes (2013)—must be calculated using the 2007 Medicare Part B non-facility participating price, as opposed to the higher 2007 Medicare Part B non-facility limiting charge, which the Third District approved in Priority Medical Center, LLC. a/a/o Susan Boggiardino v. Allstate No., 319 So. 3d 724 (Fla. 3d DCA 2021), and the Fourth District previously adopted in Allstate Fire & Casualty Insurance Co. v. Jeffrey L. Katzell, M.D., P.A., 323 So. 3d 191 (Fla. 4th DCA 2021). In receding from Katzell, the Fourth District accepted the insurer’s argument that the Medicare limiting charge does not function as a fee schedule; rather it is a term Medicare defines as an amount a provider may bill if said provider does not accept assignments of Medicare claims. The Fourth District also found that utilizing Medicare limiting charges in calculating reimbursement in the context of section 627.736(5)(a) is erroneous based on the statute’s language. For more information, see the Court’s opinion.

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