A practice manager in Wesley Chapel called us about what she described as a peer review denial. When the file arrived, it was not a peer review. It was a code audit — a vendor product that had rebundled two CPT codes and paid the difference. There was no physician opinion anywhere in it. Nobody had reviewed a chart. The letter used clinical-sounding language because the vendor’s template used clinical-sounding language, and the practice had spent three weeks preparing a medical necessity response to a denial that had nothing to do with medical necessity.
This happens constantly. Florida PIP insurers have at least five distinct tools for reducing or stopping payment, each governed by a different provision of Florida Statute § 627.736, each imposing different obligations on the carrier, and each vulnerable to a different response. Carrier correspondence blurs them, sometimes carelessly and sometimes not.
If your office is going to respond to these letters effectively — or hand them to counsel in usable shape — the threshold skill is identifying which of the five you received. This article is the field guide.
One: The Compulsory Medical Examination (the “IME”)
What it is. A physical or mental examination of your patient by a physician the insurer selects. Section 627.736(7)(a) provides that whenever the injured person’s mental or physical condition is material to a PIP claim, that person must submit to examination by a physician upon the insurer’s request.
What the insurer owes. More than most people realize.
The costs of any examination requested by an insurer are borne entirely by the insurer.
The location is regulated. The examination must be conducted within the municipality where the insured is receiving treatment, or in a location reasonably accessible to the insured. The statute defines reasonably accessible as any location within the municipality where the insured resides, or any location within ten miles by road of the insured’s residence, provided that location is within the county in which the insured resides. If no qualified physician is available within that radius, the examination must be conducted in the area of closest proximity to the insured’s residence.
That is a concrete, checkable rule, and it gets violated. A patient living in Brooksville sent to a Tampa examiner, or a patient in Bradenton scheduled in Pinellas County, is worth a hard look at the geography.
The patient is entitled to the report. Under § 627.736(7)(b), if requested by the person examined, the party causing the examination shall deliver a copy of every written report concerning the examination, and at least one of those reports must set out the examining physician’s findings and conclusions in detail. Note the word every. Note also that requesting the report or deposing the examiner waives certain privileges regarding testimony of other examining physicians, so that request is a decision, not a reflex.
What it can accomplish. An IME report can serve as the valid report supporting a withdrawal of a treating physician’s payment under § 627.736(7)(a) — but only if it satisfies every element of the valid-report definition, including that the examining physician be licensed under the same chapter as the treating physician whose authorization is being withdrawn.
The separate no-show mechanism. Section 627.736(7)(b) also provides that if a person unreasonably refuses to submit to or fails to appear at an examination, the carrier is no longer liable for subsequent PIP benefits. Two things about that sentence deserve attention. It says subsequent — it is forward-looking. And the statute provides that refusal or failure to appear at two examinations raises a rebuttable presumption that the refusal or failure was unreasonable, which means the presumption attaches at two, not one, and it is rebuttable even then.
How to spot it. Correspondence scheduling an appointment for the patient. An address and a time. A report describing a physical examination with range-of-motion findings, orthopedic testing, and observations of the patient in person.
Two: The Peer Review
What it is. A physician’s opinion based on reviewing the treatment records, with no examination of the patient. The term does not appear in the statute; the statutory concept is a report by a physician reviewing the treatment records of the injured person.
What the insurer owes. If the report is being used to withdraw payment of a treating physician, it must satisfy the valid-report requirements in § 627.736(7)(a): prepared and signed by the physician reviewing the records, factually supported by the treatment records reviewed, not modified by anyone other than the physician, authored by a Florida physician licensed under the same chapter as the treating physician, who is in active practice as the statute defines that term.
The reviewing physician must also keep copies of all examination reports as medical records for at least three years, and records of all payments for those examinations and reports for at least three years.
And the insurer — or anyone acting at its direction or on its behalf — may not materially change an opinion in the report or direct the physician to change one. The statute permits only calling errors of fact to the physician’s attention based on information in the claim file.
What it can accomplish. Where the carrier was paying and stopped, this is the document that has to hold up. Where the carrier never paid at all, the controlling appellate authority treats the claim as a denial under § 627.736(4)(b) rather than a withdrawal, and the report functions as evidence rather than as a statutory precondition. We cover that distinction in detail in a separate article in this series, and it is the single most consequential question in a peer review dispute.
How to spot it. No appointment was ever scheduled. The report recites a list of documents reviewed. The physician’s conclusions reference chart entries, not personal observations. The patient has never met this doctor.
Three: Bill Review, Code Audits, and Fee Schedule Reductions
What it is. Not a medical opinion at all. These are billing-side products — software-driven or analyst-driven reviews that recode, rebundle, or reprice your charges. They live in subsection (5) of the statute, not subsection (7).
What the insurer owes. Several things worth knowing.
On fee schedule limits: § 627.736(5)(a)1 permits an insurer to limit reimbursement to eighty percent of a schedule of maximum charges, generally two hundred percent of the applicable Medicare Part B allowable for most services, with separate treatment for emergency transport, hospital services, ambulatory surgical centers, clinical laboratories, and durable medical equipment. Critically, § 627.736(5)(a)5 permits an insurer to limit payment under that schedule only if the policy includes notice at issuance or renewal that the insurer may do so. A carrier applying fee schedule limits under a policy without that notice has a problem.
Also under § 627.736(5)(a)3: an insurer applying those payment limitations must reimburse a provider who lawfully provided care within the scope of his or her license, regardless of whether that provider would be entitled to reimbursement under Medicare due to restrictions on which disciplines may bill particular codes. The statute permits use of Medicare coding policies and payment methodologies, including modifiers, but not utilization limits.
On upcoding and unbundling: § 627.736(5)(b)1.e permits an insurer to change codes it determines were improperly upcoded or unbundled and pay on the changed codes. But before doing so, the insurer must contact the health care provider and discuss the reasons for the insurer’s change and the provider’s reason for the coding — or make a reasonable good faith effort to do so, documented in the insurer’s file. That is an affirmative obligation. If nobody from the carrier ever called your office before recoding your bills, ask what is in that file.
On downcoding: § 627.736(5)(g) provides that an insurer may not systematically downcode with the intent to deny reimbursement otherwise due, and that such action constitutes a material misrepresentation under § 626.9541(1)(i)2.
What it cannot accomplish. A bill review product is not a physician’s report. It cannot satisfy § 627.736(7)(a) and cannot support a withdrawal of a treating physician’s treatment authorization on reasonableness, relatedness, or necessity grounds.
How to spot it. Line-item math. CPT codes with modifiers. Language about allowable amounts, multiple procedure reductions, bundling edits, or usual and customary charges. No physician signature, or a signature from someone with no stated clinical relationship to the review.
Four: The § 627.736(6)(b) Records and Sworn Statement Request
What it is. Not a denial at all, which is why practices misread it. Section 627.736(6)(b) permits an insurer to require a provider to furnish a written report of the history, condition, treatment, dates, and costs of treatment, and why the items the insurer identified were reasonable in amount and medically necessary — together with a sworn statement that the treatment or services were reasonable and necessary, in the specific form the statute prescribes, and to allow inspection and copying of records.
What the insurer owes. The person requesting the records and sworn statement must pay all reasonable costs connected with it.
There is also a timing consequence that runs in the provider’s favor. If the insurer makes a written request under this paragraph within thirty days after receiving notice of the amount of a covered loss, the amount subject to the inquiry is overdue if the insurer does not pay within the ordinary period or within ten days after receiving the requested documentation, whichever is later. The clock does not stop indefinitely.
And § 627.736(6)(b) provides that an insurer that requests documentation or information pertaining to reasonableness of charges or medical necessity under that paragraph without a reasonable basis, as a general business practice, engages in an unfair trade practice under the insurance code.
How to spot it. It asks you for something rather than telling you something. It references a sworn statement. It usually arrives before any denial and is frequently the prelude to one.
Five: The Examination Under Oath
What it is. A recorded, sworn examination of the insured. Section 627.736(6)(g) provides that an insured seeking benefits must comply with the terms of the policy, including submitting to an examination under oath, that the scope of questioning is limited to relevant information or information reasonably expected to lead to relevant information, and that compliance is a condition precedent to receiving benefits.
What constrains it. The scope limitation is real and is written into the statute. And an insurer that, as a general business practice as determined by the Office of Insurance Regulation, requests an examination under oath without a reasonable basis is subject to § 626.9541.
How to spot it. It involves the patient, not the records, and it involves a court reporter. We address EUO no-show denials in a separate article.
Telling Them Apart at a Glance
Was your patient examined in person by a doctor the insurer chose? IME.
Did a doctor read the chart without examining the patient? Peer review.
Is the dispute about codes, modifiers, bundling, or allowable amounts, with no physician opinion? Bill review or fee schedule reduction.
Did the carrier ask your office for records and a sworn statement? A § 627.736(6)(b) request — not yet a denial.
Did the carrier want the patient under oath with a court reporter? EUO.
Received two or three of these at once? That is common, and each component needs its own response. A single letter frequently contains a fee schedule reduction on some codes and a medical necessity denial on others.
Why This Matters More Than It Sounds
Misidentifying the denial type costs practices real money in three ways.
Wrong response, wasted effort. Preparing a medical necessity narrative for a bundling edit accomplishes nothing. Neither does arguing coding to a peer review physician.
Wrong demand letter. Section 627.736(10) sets out what a demand must contain, and it treats a withdrawal of payment for future treatment not yet rendered differently from an ordinary overdue claim — requiring the withdrawal notice and an itemized statement of the type, frequency, and duration of the future treatment claimed to be reasonable and medically necessary. A demand drafted for the wrong track may not satisfy the condition precedent for the relief actually sought.
Missed defects. Each category carries its own statutory requirements, and each set of requirements is a set of potential failures. The policy-notice requirement for fee schedule limits, the pre-recoding contact obligation, the IME location rules, the same-chapter requirement — none of these can be found if the letter was filed under the wrong heading in the first place.
How Licznerski Law, PLLC Approaches These Denials
We represent the injured patient — the named insured under the policy. Your practice is not our client, signs nothing, and pays us nothing at any stage. There is no cost to your office to send us a denial and have us tell you what it actually is.
That structure follows from the fee law. HB 837, effective March 24, 2023, eliminated the one-way attorney fee provision that made provider-assignee PIP suits economically workable. The fee right remaining in declaratory judgment actions under § 86.121 belongs to the named insured and is not assignable, which is why the patient must be the plaintiff and why we revoke the assignment of benefits at the outset.
We will also tell you plainly that Florida trial courts are divided on what “total coverage denial of a claim” means under § 86.121. We have obtained favorable rulings on that question and we have received adverse ones. No binding appellate decision has resolved the split on the merits.
We handle these denials for patients treated at practices throughout Hillsborough, Pinellas, Pasco, Hernando, Citrus, Polk, Manatee, and Sarasota Counties, including Tampa, St. Petersburg, Clearwater, Brandon, Riverview, Plant City, Palm Harbor, Largo, Safety Harbor, Wesley Chapel, Land O’ Lakes, New Port Richey, Spring Hill, Brooksville, Inverness, Lakeland, Bradenton, and Sarasota.
Frequently Asked Questions
Is a peer review the same thing as an IME?
No. An IME involves a physical examination of the patient by a physician the insurer selects. A peer review involves no examination — the physician reviews records only. Both can potentially serve as the report supporting a withdrawal of payment, but only if the statutory valid-report requirements are met.
How far can an insurer make our patient travel for an IME?
Section 627.736(7)(a) requires the examination to be within the municipality where the insured is receiving treatment, or in a location reasonably accessible to the insured — defined as within the municipality of the insured’s residence, or within ten miles by road of the residence and inside the county of residence. If no qualified physician is available in that area, the exam must be in the closest available proximity to the residence.
Can a bill review company cut off our patient’s treatment authorization?
A bill review product is not a physician’s report and cannot satisfy § 627.736(7)(a). It can affect what gets paid on submitted charges under subsection (5), which is a different question.
The carrier recoded our bills without ever contacting us. Is that allowed?
Section 627.736(5)(b)1.e requires the insurer, before changing codes it deems upcoded or unbundled, to contact the provider and discuss the reasons for the change and the provider’s reason for the coding — or to make a reasonable good faith effort to do so, documented in its file. Whether that was satisfied in a given case is a factual question worth asking about.
We got a letter asking for records and a sworn statement. Is that a denial?
No. That is a request under § 627.736(6)(b). The insurer must pay the reasonable costs connected with it, and the payment clock does not stop indefinitely while it is pending.
What does a review cost our practice?
Nothing. We are retained by the patient. Your office pays no fee at any point.
Contact Licznerski Law, PLLC — Send Us the Letter Before You Draft a Response
If you are not certain what kind of denial you received, that is the most common and most expensive problem in Florida PIP. Send it over. We will tell you what it is, what the carrier was required to do before issuing it, and whether it holds up.
Call Licznerski Law, PLLC at 813-934-3519, email [email protected], or visit www.licznerskilaw.com.