Below are Florida workers’ compensation reimbursement and fee schedule requirements, including payment rules for providers, hospitals, and ambulatory surgical centers.
RBRVS System
Florida uses the Resource-Based Relative Value Scale (RBRVS) to determine reimbursement rates for workers’ compensation medical billing.
Hospitals and Ambulatory Surgical Centers (ASCs)
- Hospitals and ASCs must be reimbursed at their contracted rate or the state’s maximum reimbursement allowance (MRA), whichever applies.
Emergency Services
- If no allowance applies, Emergency Services must be reimbursed at 250% of Medicare, unless a contracted rate exists.
Maximum Reimbursement
- Physicians: Must be reimbursed at 175% of the Medicare allowance, using the correct codes and modifiers or the medical reimbursement level adopted by the three-member panel, whichever is greater.
- Surgical Procedures:
Maximum Reimbursement for Surgical Procedures
- Surgical procedures must be reimbursed at 210% of the Medicare allowance.
- Alternatively, reimbursement follows the medical reimbursement level adopted by the three-member panel, whichever is greater.
Unlisted Procedure Codes
Providers may bill new or valid CPT®/HCPCS Level II® codes that are effective on the service date.
If the code is not listed in the fee schedule, reimbursement is based on:
- A clinically similar listed code,
- Supporting documentation and bills, or
- The National Physician Fee Schedule Relative Value File.
At a minimum, reimbursement must equal either:
- The MRA for a clinically similar code, or
- An agreed-upon contracted rate.
Florida |
Statute/Rule |
Statute |
|
Section |
440.13 Medical Services and Supplies; Penalty for Violations; Limitations |
Subsection Text |
440.13 (12) (d) 1. Outpatient reimbursement for scheduled surgeries shall be 60 percent of charges. 2. Reimbursement for emergency services and care as defined in s. 395.002 which does not include a maximum reimbursement allowance must be 250 percent of Medicare, unless there is a contract, in which case the contract governs reimbursement. Upon this subparagraph taking effect, the department shall engage with an actuarial services firm to begin development of maximum reimbursement allowances for services subject to the reimbursement provisions of this subparagraph. This subparagraph expires June 30, 2026.
440.13 (12) (f) Maximum reimbursement for a physician licensed under chapter 458 or chapter 459 shall be 175 percent of the reimbursement allowed by Medicare, using appropriate codes and modifiers or the medical reimbursement level adopted by the three-member panel as of January 1, 2003, whichever is greater.
440.13 (12) (g) Maximum reimbursement for surgical procedures shall be 210 percent of the reimbursement allowed by Medicare or the medical reimbursement level adopted by the three-member panel as of January 1, 2003, whichever is greater.
440.13 (12) (i) Reimbursement for all fees and other charges for such treatment, care, and attendance, including treatment, care, and attendance provided by any hospital or other health care provider, ambulatory surgical center, work-hardening program, or pain program, must not exceed the amounts provided by the uniform schedule of maximum reimbursement allowances as determined by the panel or as otherwise provided in this section. This subsection also applies to independent medical examinations performed by health care providers under this chapter. In determining the uniform schedule, the panel shall first approve the data which it finds representative of prevailing charges in the state for similar treatment, care, and attendance of injured persons. Each health care provider, health care facility, ambulatory surgical center, work-hardening program, or pain program receiving workers’ compensation payments shall maintain records verifying their usual charges. In establishing the uniform schedule of maximum reimbursement allowances, the panel must consider: 1. The levels of reimbursement for similar treatment, care, and attendance made by other health care programs or third-party providers; 2. The impact upon cost to employers for providing a level of reimbursement for treatment, care, and attendance which will ensure the availability of treatment, care, and attendance required by injured workers; and 3. The financial impact of the reimbursement allowances upon health care providers and health care facilities, including trauma centers as defined in s. 395.4001, and its effect upon their ability to make available to injured workers such medically necessary remedial treatment, care, and attendance. The uniform schedule of maximum reimbursement allowances must be reasonable, must promote health care cost containment and efficiency with respect to the workers’ compensation health care delivery system, and must be sufficient to ensure availability of such medically necessary remedial treatment, care, and attendance to injured workers. |
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