The insurer sends your patient to a doctor of its own choosing. The patient goes, or misses the appointment, and either way the report comes back saying no further treatment is warranted. Days later, the insurer terminates benefits and stops paying. For many Tampa Bay providers, that letter reads like a wall: the independent medical examination is done, the insurer has spoken, and the claim is over.
It is not a wall, and treating it like one costs practices real money. An IME cutoff is one of the most misunderstood tools in the PIP insurer’s playbook, and two features of Florida law — the standard for what actually justifies a cutoff, and the strict limit on how far back a cutoff can reach — routinely leave far more of your bill recoverable than the termination letter suggests.
What an IME Is, and How Insurers Use It
An independent medical examination, or IME, is a physical or mental examination of the injured person performed by a physician the insurer selects and pays. It is different from a peer review, which is a records-only review with no examination. The IME involves the patient in person, and insurers use it for two related purposes: to generate an opinion that ongoing care is no longer reasonable, related, or necessary, and to create a basis to argue the patient failed to cooperate when an appointment is missed.
The authority comes from Florida Statute 627.736(7). When the mental or physical condition of an injured person is material to a claim for PIP benefits, the person must, at the insurer’s request, submit to an examination by a physician. That is a real obligation. But the statute hedges it with limits that insurers routinely gloss over in their cutoff letters.
The “Unreasonable Refusal” Standard: One Missed Appointment Is Not an Automatic Bar
When an insurer terminates benefits because a patient did not attend an IME, the question the statute actually asks is whether the refusal to submit was unreasonable. The word matters. The statute does not say that any missed appointment ends the claim; it says that an unreasonable refusal relieves the insurer of liability for subsequent benefits. Reasonableness is a fact-specific inquiry, and the facts frequently favor the patient and, by extension, you.
Consider what an insurer must overcome. Was the examination noticed properly, with enough time for the patient to arrange to attend? Was the location reasonable, or was a patient recovering from a crash directed to travel an unreasonable distance? Did the patient attempt to reschedule, or have a legitimate reason — work, transportation, a medical conflict — for missing the date? A patient who tried in good faith to accommodate the examination, or who was set up to fail by unreasonable scheduling, has not necessarily engaged in the unreasonable refusal the statute requires. A single missed appointment, standing alone and surrounded by good-faith conduct, is a thin foundation for terminating an entire course of care, and insurers build cutoffs on exactly that foundation all the time.
The Prospective-Only Limit: The Point Providers Miss Most
Here is the feature that puts money back in your practice, and it is the one providers overlook most often.
An IME cutoff is prospective only. When an insurer terminates benefits based on an IME — whether on a no-show theory or on the examiner’s opinion that no further care is needed — that termination can reach forward to bar payment for treatment rendered after the cutoff. It does not reach backward to erase your right to payment for reasonable, related, and necessary care you already provided before the cutoff took effect.
Read the statute’s own language: an unreasonable refusal relieves the insurer of liability for subsequent benefits. Subsequent. The care you delivered before the missed examination or before the IME opinion is not subsequent to anything. It was properly incurred, and the cutoff does not wipe it out.
This distinction has direct financial consequences. Picture a patient you treated across several weeks before an IME was ever scheduled. The insurer sends the patient to its examiner, then terminates benefits and stops paying — including refusing the balance for all that earlier treatment. Providers routinely absorb that entire loss because the termination letter is written to sound comprehensive. But the earlier balance was never properly subject to the cutoff. When a provider assumes an IME termination erases everything and walks away, the insurer keeps money it had no right to keep. Separating the pre-cutoff balance from any legitimately terminated future care is often the single most valuable step in challenging an IME denial.
Where IME Cutoffs Break Down
Beyond the two core issues, IME-based terminations carry the same kinds of defects that undermine other PIP denials.
Scheduling and notice failures. An IME requires proper, reasonable notice and a reasonable location and time. Defects here weaken any argument that a missed appointment was an unreasonable refusal.
An opinion that is not well supported. When a cutoff rests on the examiner’s opinion that further care is unnecessary, that opinion has to be credible and grounded in the actual clinical picture. An examiner’s brief, conclusory report can be weighed against your detailed treatment records and the documented course of the patient’s recovery.
Overbroad application. Insurers sometimes stretch a single IME opinion to justify sweeping terminations across services and time periods the examination never actually addressed. The real scope of what an IME supports is narrower than the cutoff letter often claims.
Inconsistent insurer conduct. An insurer that continues to request records, makes partial payments, or otherwise acts inconsistently with the cutoff it later asserts may have undercut its own position.
How Licznerski Law, PLLC Approaches IME Denials
We take the termination letter apart rather than taking it at face value. First, we separate what the cutoff can legitimately reach from what it cannot — isolating the pre-cutoff balance for reasonable, related, and necessary care that was properly incurred and is not subject to a prospective termination at all. Then we test the cutoff itself: Was the IME properly noticed and reasonably scheduled? If the insurer alleges a no-show, was the patient’s conduct actually an unreasonable refusal, or was it good-faith or excused? If the cutoff rests on the examiner’s opinion, is that opinion supported and does it hold up against your records? Did the insurer stretch a narrow IME into a broad termination it cannot support?
From there we build the claim. We confirm the assignment of benefits is sound and that the demand letter under Florida Statute 627.736(10) meets the statute’s requirements, and where an insurer wrongfully refuses to pay, we use proposals for settlement under Florida Statute 768.79 to shift fee exposure back onto the insurer and are prepared to litigate and try the case. We represent chiropractors, physical therapists, pain management practices, imaging centers, and other medical providers throughout Tampa, St. Petersburg, Clearwater, Palm Harbor, and across Pinellas and Hillsborough counties.
This article is part of our complete guide to fighting wrongful PIP denials for Tampa Bay medical providers, which connects the IME issue to the EUO, peer review, and fee-schedule tactics insurers use alongside it.
Contact Licznerski Law, PLLC — An IME Cutoff Rarely Reaches as Far Back as the Letter Implies
If an insurer has terminated benefits based on an independent medical examination, some or all of your balance may still be recoverable — especially the care you provided before the cutoff. Let us review it. We will tell you candidly what the cutoff can and cannot reach and what we can pursue on your behalf.
Call Licznerski Law, PLLC today at 813-934-3519, or visit www.licznerskilaw.com to start the conversation. Insurers write these letters to sound final. The law says otherwise.
Licznerski Law, PLLC — When Insurers Bet That You Won’t Fight, We Make Them Pay.