The letter arrives on a Tuesday. Four paragraphs of clinical-sounding prose, a physician’s signature at the bottom, and a conclusion stated as though it were a finding of fact: the treatment your practice rendered was not reasonable, not related to the motor vehicle accident, or not medically necessary. Attached is an explanation of benefits showing zeroes where payment should be. Your patient — mid-course, still symptomatic, still on your schedule — has just been told that Florida PIP will no longer pay for their care.
Nobody examined the patient. Nobody called your office. Nobody asked what the records actually show. A physician your patient has never met read some or all of a chart and wrote a report, and a claims adjuster in another county acted on it.
This is a peer review denial, and across Hillsborough, Pinellas, Pasco, Hernando, Citrus, Polk, Manatee, and Sarasota Counties it has become the single most common mechanism Florida PIP insurers use to shut off benefits. Chiropractic practices in Tampa, Brandon, and Riverview see them constantly. So do physical medicine clinics in St. Petersburg, Clearwater, and Largo, pain management practices in Wesley Chapel and New Port Richey, and imaging centers serving Spring Hill, Lakeland, Bradenton, and Sarasota.
Here is what most practice managers do not know: Florida law does not let an insurer suspend a treating physician’s authorization on just any report. The statute sets out specific, enforceable requirements for what that report must be, who must write it, and what it must be built on. A substantial number of peer review reports circulating in Florida PIP claims fail at least one of those requirements on their face — visible from the document itself, before anyone argues about the medicine.
This article is the anchor for our full series on peer review denials. It walks through what the statute actually requires, the categories of defect we see most often, and what a Tampa Bay practice should do in the first thirty days after a report lands.
What a Peer Review Actually Is — and What It Is Not
The term “peer review” appears nowhere in the Florida PIP statute. It is industry vocabulary, not statutory vocabulary, and that ambiguity works in the insurer’s favor.
What the statute contemplates is a report — either from a physician who examined the injured person, or from a physician who reviewed the treatment records. In practice, the industry has split these into two products. A compulsory medical examination, commonly called an IME, involves an actual physical examination of the patient by a physician the insurer selects. A peer review involves no examination at all; the physician reads the chart and the billing and writes an opinion.
These are legally distinct events with distinct consequences, and providers routinely conflate them because insurers use the terms loosely in correspondence. You will also encounter a third category — bill review, code audits, and utilization review products generated by vendors that are not medical opinions at all and cannot support a withdrawal of treatment authorization under the statute.
Knowing which one you actually received is the first analytical step, because the defenses differ completely. We cover that distinction in detail in a companion article in this series.
The Statute: What Florida Law Requires Before an Insurer Can Withdraw Payment
The operative language is Florida Statute § 627.736(7)(a). It is worth reading slowly, because insurers rely on providers never reading it at all.
The statute provides that an insurer may not withdraw payment of a treating physician without the consent of the injured person, unless the insurer first obtains a valid report by a Florida physician licensed under the same chapter as the treating physician whose treatment authorization is sought to be withdrawn, stating that treatment was not reasonable, related, or necessary.
The statute then defines what makes a report valid. A valid report is one that is prepared and signed by the physician examining the injured person or reviewing the treatment records, is factually supported by the examination and treatment records if reviewed, and has not been modified by anyone other than the physician.
The statute adds further requirements. The physician preparing the report must be in active practice, unless physically disabled. Active practice means that in the three years immediately preceding the examination or the record review, the physician devoted professional time to the active clinical practice of evaluation, diagnosis, or treatment of medical conditions, or to instruction in an accredited health professional school, accredited residency program, or affiliated clinical research program.
The statute imposes recordkeeping duties. The physician preparing a report at an insurer’s request must keep copies of all examination reports as medical records for at least three years, and must keep records of all payments for those examinations and reports for at least three years.
And the statute contains a provision that insurers would prefer nobody notice. Neither an insurer nor any person acting at its direction or on its behalf may materially change an opinion in a report prepared under that paragraph, or direct the physician preparing the report to change such an opinion. A denial of payment resulting from such a changed opinion constitutes a material misrepresentation under § 626.9541(1)(i)2. The statute permits only one narrow exception — an insurer may call errors of fact to the physician’s attention based on information in the claim file.
Read together, these are not aspirational standards. They are conditions the insurer has to satisfy before it can lawfully do what its letter says it has done.
The Ways Peer Review Denials Fail
Across the peer review reports we review for patients treated in Tampa Bay practices, defects tend to cluster into recognizable categories. Some are visible on the face of the document. Others require discovery to surface.
The wrong licensing chapter. The statute requires a physician licensed under the same chapter as the treating physician whose authorization is being withdrawn. Chiropractic physicians are licensed under Chapter 460. Medical doctors are licensed under Chapter 458. Osteopathic physicians are licensed under Chapter 459. Podiatric physicians are licensed under Chapter 461. Dentists are licensed under Chapter 466. When an insurer suspends a chiropractic physician’s treatment on a report authored by a medical doctor, the chapters do not match. The statute does not say “a similarly qualified physician” or “a physician in a related field.” It says the same chapter. This is the most frequently encountered defect and the subject of its own article in this series.
The physician is not Florida licensed. The statute says a Florida physician. Peer review vendors operate nationally, and reports authored by out-of-state physicians appear in Florida PIP files with some regularity. Check the license number and the state of licensure on the signature block. It is a thirty-second check.
The physician is not in active practice. The three-year active practice requirement is a real limitation, and it is one of the least examined. Physicians who have wound down clinical work and now generate review reports as their primary professional activity may not satisfy it. This ordinarily requires discovery to establish, but the recordkeeping obligations the statute imposes give a roadmap for where to look.
The report is not factually supported by the records reviewed. This is where template drafting becomes a liability for the carrier. When a report recites findings that do not appear in your chart, omits objective findings that do appear, describes a treatment course that does not match your daily notes, or reaches conclusions about records the physician never actually received, the statutory requirement of factual support is in play. Comparing the report against what your office actually produced — and against what the insurer actually forwarded to the reviewer — is often the most productive single exercise in the entire dispute.
The report was modified by someone other than the physician. The statute is unambiguous that a valid report is one not modified by anyone other than the physician, and separately prohibits the insurer or anyone acting on its behalf from materially changing an opinion or directing that it be changed. Where a vendor’s editorial staff, a case manager, or an adjuster participates in shaping the report, the statutory problem is significant — and the statute characterizes a denial resulting from a changed opinion as a material misrepresentation. Because this defect lives in the vendor’s files rather than on the face of the report, it is a discovery issue. We treat it separately in this series because, in our view, it is the most consequential and least litigated defect in Florida peer review practice.
The report is used to do something it cannot do. A § 627.736(7)(a) report is what an insurer needs to withdraw payment of a treating physician. That is a narrower authority than most denial letters suggest. Separately, § 627.736(4)(b)6 permits an insurer to assert that a claim was unrelated, not medically necessary, or unreasonable at any time, including after payment. The relationship between those two provisions — what a peer review report is required for, what it is not required for, and how far backward its effect can reach — drives a meaningful share of PIP litigation and deserves its own treatment.
Withdrawal Versus Denial: Why the Distinction Matters to Your Practice
Practice managers often read a peer review letter as a single global event: the insurer stopped paying. Legally, the letter may be doing two very different things at once.
To the extent the insurer is cutting off authorization for treatment going forward, it is withdrawing payment of a treating physician, and § 627.736(7)(a) governs. To the extent the insurer is refusing to pay bills already submitted for treatment already rendered, a different analysis applies, and the insurer will argue it needs no report at all.
That distinction shapes everything downstream — what your demand letter must contain, what relief is available, and how the claim gets postured. Section 627.736(10)(b)3 recognizes the difference explicitly: where a demand involves an insurer’s withdrawal of payment under paragraph (7)(a) for future treatment not yet rendered, the claimant must attach the insurer’s withdrawal notice and an itemized statement of the type, frequency, and duration of the future treatment claimed to be reasonable and medically necessary.
Practices that treat a peer review letter as a single undifferentiated denial frequently send demand letters that address only half of what happened.
What a Tampa Bay Practice Should Do in the First Thirty Days
Preserve the entire packet. The report, the transmittal letter, the explanation of benefits, the envelope, and every page of the records your office produced. What the insurer sent to the reviewer, and what it withheld, is frequently the heart of the dispute.
Read the signature block first. State of licensure, license number, chapter of licensure, and specialty. Compare against the treating provider’s chapter. This single comparison resolves a meaningful percentage of these reports before anyone reaches the medicine.
Compare the report to the chart, line by line. Note every finding recited that does not appear in your records, and every objective finding in your records that the report does not address.
Identify what the letter is actually doing. Prospective cutoff, retroactive refusal on already-rendered treatment, or both. Date-of-service specificity matters.
Determine whether the carrier has paid anything on this claim. Note the amounts and dates. This affects which procedural routes remain available, for reasons discussed below.
Do not discharge the patient because the carrier stopped paying. A patient who still needs care and still has coverage available is in a different position than the denial letter implies. Clinical decisions should stay clinical.
How Licznerski Law, PLLC Approaches Peer Review Denials — and Who Our Client Is
Our model differs from most firms that market to medical providers, and the difference matters to your practice financially.
We represent the injured patient — the named insured under the policy. Your practice is not our client, does not sign a retainer with us, and does not pay us a fee. There is no cost to your office for us to review a peer review report, and no cost to your office if we pursue the claim. We are retained by the patient, we revoke the assignment of benefits so the patient holds the claim, and we litigate against the carrier on the patient’s behalf.
That structure exists for a specific legal reason. HB 837, effective March 24, 2023, eliminated the one-way attorney fee provision that previously made provider-assignee PIP suits economically viable. Under current law, a provider suing as assignee ordinarily bears its own legal costs regardless of outcome. The fee right that remains available in declaratory judgment actions under § 86.121 belongs to the named insured and is not assignable — which is why the patient, not the practice, has to be the plaintiff.
We will be candid with you about the state of that law, because we would rather you hear it from us than from a defense lawyer. Florida trial courts are currently divided on what the phrase “total coverage denial of a claim” means in § 86.121 — whether it refers to each denied bill or to the aggregate PIP claim arising from one accident. We have obtained favorable rulings on this question from multiple judges in Hillsborough and Orange Counties. We have also received adverse rulings, including one in which the court struck the claim because the insurer had made prior partial payments on the file. There is no binding appellate decision resolving the split on the merits. Any firm telling providers this route is settled and risk-free is not telling you the truth.
What we can tell you is that the peer review report itself is where these cases are usually won or lost, and that a large share of the reports we examine have identifiable statutory problems.
We review peer review 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
Can a medical doctor write a peer review report that cuts off chiropractic treatment?
Section 627.736(7)(a) requires a Florida physician licensed under the same chapter as the treating physician whose treatment authorization is being withdrawn. Chiropractic physicians are licensed under Chapter 460 and medical doctors under Chapter 458. Whether a particular report satisfies the statute depends on its specific facts, but the chapter comparison is the starting point and is often where the analysis ends.
Does the peer review doctor have to examine my patient?
Not necessarily. The statute contemplates a report from a physician who either examines the injured person or reviews the treatment records. A records-only review can qualify — but if it is a records review, the statute requires the report to be factually supported by the treatment records reviewed.
The insurer says the peer review is final. Is it?
No. A peer review report is the insurer’s evidence, not an adjudication. It is subject to challenge on the statutory requirements described above and on the medicine itself.
Can the insurer take back money it already paid us?
That question turns on what the letter is actually doing and on the specific dates of service involved. Retroactive application of a peer review report raises different issues than a prospective cutoff, and the two are frequently combined in a single letter.
Does my practice pay anything for you to look at a denial?
No. We are retained by the patient, not the practice. Your office pays no fee at any stage.
What do you need from us to review a denial?
The peer review report, the explanation of benefits, the insurer’s correspondence, and the treatment records for the patient at issue.
Contact Licznerski Law, PLLC — Send Us the Report Before You Write Off the Claim
If a PIP insurer has suspended your patient’s benefits on a peer review report, send it to us and let us look at it. We will tell you candidly whether the report has statutory problems, whether the denial is worth challenging, and what we can pursue on the patient’s behalf. If the answer is that the denial is sound, we will tell you that too.
Call Licznerski Law, PLLC at 813-934-3519, email [email protected], or visit www.licznerskilaw.com. There is no cost to your practice for the review, and no fee to your practice at any point.
Licznerski Law, PLLCw — When Insurers Bet That You Won’t Fight, We Make Them Pay.