Two practices, two letters, same week.
A chiropractic office in Riverview had been paid on eleven dates of service over about seven weeks. Then a peer review report landed, and the payments stopped cold.
A physical medicine practice in Largo submitted its first bills on a new patient and got nothing. No partial payment, no reduction, just zeroes — and a peer review report saying the care was not reasonable, related, or necessary.
Both letters look nearly identical. Both cite the same statute. Both practice managers read them the same way: the insurer got a peer review and cut us off.
Under Florida law, those two situations are not the same case, and the difference is not a technicality. It determines what the insurer had to do before it acted, what defenses it can raise later, and how hard the denial is to challenge. Practices across Hillsborough, Pinellas, Pasco, Hernando, Citrus, Polk, Manatee, and Sarasota Counties fight these claims without ever making the distinction — and it is the first question we ask.
Two Statutory Tracks
Florida Statute § 627.736 contains two provisions that both bear on reasonableness, relatedness, and necessity, and they operate very differently.
Track one is § 627.736(7)(a). It provides that an insurer may not withdraw payment of a treating physician without the injured person’s consent unless it 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physician licensed under the same chapter as the treating physician whose treatment authorization is sought to be withdrawn, stating that treatment was not reasonable, related, or necessary.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 such a report valid — prepared and signed by the physician, factually supported by the records reviewed, unmodified by anyone other than the physician, authored by a physician in active practice.
That is a demanding set of conditions, and it is a precondition. The insurer must satisfy it first.
Track two is § 627.736(4)(b). It governs when benefits become overdue, and it contains two provisions that matter here. Subparagraph 4 provides that payment is not overdue if the insurer has reasonable proof that it is not responsible for the payment. Subparagraph 6 provides that the paragraph does not preclude or limit the insurer’s ability to assert that a claim was unrelated, was not medically necessary, or was unreasonable, or that the charge exceeded what subsection (5) permits — and that such an assertion may be made at any time, including after payment of the claim or after the thirty-day payment period.
At any time. That phrase is doing enormous work, and insurers know it.
How Florida Courts Have Reconciled Them
The relationship between these two provisions has been litigated hard, and the answer moved over time.
The earlier authority, from the Third District Court of Appeal, read the valid-report requirement broadly — as applying where an insurer reduced, withdrew, or denied benefits on reasonableness, relatedness, or necessity grounds. Providers had a powerful argument that any peer-review-driven refusal to pay required a statutorily compliant report first, and that a defective report meant the defense was gone entirely.
That is no longer the law. Sitting en banc, the Third District receded from the portion of its earlier decisions suggesting the valid-report requirement reached denials as well as withdrawals. The court held that § 627.736(4)(b) does not require an insurer to obtain a valid medical report before denying payment of a claim. A companion decision confirmed that a valid report is not a condition precedent to a denial or a partial reduction of medical bills.
The court later put the practical rule plainly: where no payments have been made, resulting in a total rejection of a provider’s bills, § 627.736(4) governs. That provision permits the insurer to deny the claim at any time, before or after it becomes overdue, so long as it has reasonable proof that it is not responsible for payment. A § 627.736(7)(a) report may serve as that proof — but it is not required in order to deny.
Two things about that authority deserve emphasis.
First, these are decisions of the Third District, out of Miami-Dade, not the districts covering Tampa Bay. But Florida trial courts generally treat a district court of appeal decision as controlling in the absence of contrary authority from their own district. Defense counsel in Hillsborough and Pinellas County cite this line routinely, and trial courts here generally follow it.
Second, this authority narrows the valid-report argument. It does not eliminate it. The statute still says what it says about withdrawal, and the courts left that intact.
The Practical Rule
Here is the distinction, stated as plainly as we know how.
If the insurer was paying and then stopped, it withdrew payment of a treating physician. Section 627.736(7)(a) applies. The insurer needed a valid report — same licensing chapter, Florida licensed, in active practice, factually supported by the records reviewed, unmodified — before it acted. Every defect in that report is in play, and the defects are frequently there.
If the insurer never paid anything on the claim, it denied rather than withdrew. Under the controlling appellate authority, § 627.736(4)(b) governs, the insurer may contest reasonableness, relatedness, and necessity at any time, and it did not need a compliant report to do so. The peer review report is still attackable — but as evidence, on its persuasiveness and reliability, not as a failed statutory precondition.
The middle cases are messier and more common than either clean scenario. Payment on some dates of service and zeroes on others. Payment on one CPT code and rejection of another. Payment to one provider in a practice and not to a second. Whether any of that constitutes a withdrawal as to particular treatment is fact-specific, and it is where a great deal of the real litigation happens.
A Crosscurrent Worth Understanding
There is a strategic tension here that we think providers should hear about directly, because it cuts against our own interest in keeping the pitch simple.
The valid-report argument under § 627.736(7)(a) is strongest when the carrier paid and then stopped.
The declaratory judgment route under § 86.121 — the mechanism by which the named insured can recover attorney fees from the carrier after HB 837 eliminated one-way fees — turns on a total coverage denial of a claim. We have had a claim struck by a Hillsborough County court on exactly this ground, because the insurer had made prior partial payments on the file.
So the fact pattern that makes the strongest peer review challenge can be the fact pattern that complicates the fee route, and the fact pattern that supports the fee route can be the one where the valid-report argument is hardest.
We are not going to pretend that tension does not exist. It does. It means these files need to be assessed individually rather than sorted into a template, and it means the payment history on a claim is the first thing we look at — before the medicine, before the report, before anything else.
What the Insurer Still Owes You, Even in a Denial Case
A denial case is not a lost case. The statute imposes obligations that do not disappear because the carrier never paid.
Reasonable proof. Section 627.736(4)(b)4 conditions the insurer’s position on having reasonable proof that it is not responsible for payment. That is a substantive requirement with content, and a report that misstates the record, addresses treatment that was never rendered, or reaches conclusions unsupported by the chart is worth testing against it.
Itemization at the time of rejection. Section 627.736(4)(b)2 requires that when an insurer pays only a portion of a claim or rejects it, the insurer must provide, at the time of the partial payment or rejection, an itemized specification of each item it reduced, omitted, or declined to pay, along with any information the insurer wants the claimant to consider regarding medical necessity of the denied treatment or the reasonableness of a reduced charge. It must also identify the person to respond to and a claim number. Blanket zeroes with no itemization do not meet that standard.
Restraint on document requests. Section 627.736(6)(b) provides that an insurer that requests documentation or information concerning reasonableness of charges or medical necessity without a reasonable basis, as a general business practice, engages in an unfair trade practice under the insurance code.
The report is still evidence, and evidence can be attacked. Reviewer credentials, volume of review work, financial relationship with the carrier, factual accuracy, and the completeness of the records actually furnished are all fair game — regardless of whether the report was a statutory precondition.
What This Means for Your Demand Letter
Section 627.736(10) requires written notice of intent to initiate litigation as a condition precedent to suit, and it treats withdrawals differently from ordinary claims.
Where the demand involves an insurer’s withdrawal of payment under paragraph (7)(a) for future treatment not yet rendered, the claimant must attach a copy of the insurer’s notice withdrawing payment and an itemized statement of the type, frequency, and duration of the future treatment claimed to be reasonable and medically necessary.
The insurer’s escape route differs too. On an ordinary overdue claim, the carrier avoids suit by paying within thirty days with interest and a penalty of ten percent of the overdue amount, capped at two hundred fifty dollars. On a withdrawal of payment for future treatment not yet rendered, the carrier avoids suit by mailing, within thirty days, a written statement agreeing to pay for that treatment in accordance with the notice, plus the same capped penalty when it pays.
A demand letter drafted for the wrong track can fail to satisfy the condition precedent for the relief actually sought. This is a routine and avoidable problem.
What Your Practice Should Do First
Pull the payment history before anything else. Every dollar the carrier paid on this claim, to every provider, on every date of service. This single question drives the entire analysis.
Identify what the letter covers by date of service. Prospective cutoff, retroactive refusal, or both. Denial letters routinely do both without saying so.
Check whether the carrier itemized. Compare what you billed against what the explanation of benefits actually specifies as reduced, omitted, or declined.
Note the sequence. Date the carrier stopped paying, date of the peer review report, date of the suspension letter. Order matters, particularly on a withdrawal.
Do not assume a total rejection is unwinnable. It is a different case, not a hopeless one — and the fee posture may actually be better.
How Licznerski Law, PLLC Approaches These Claims
We represent the injured patient — the named insured. Your practice is not our client, signs nothing, and pays us nothing at any stage. There is no cost to your office for us to review a denial and tell you which track it falls on.
That structure follows from the law. HB 837, effective March 24, 2023, eliminated the one-way attorney fee provision that made provider-assignee PIP suits economically viable. The fee right that remains 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 be straight with you about that route as well. Florida trial courts are divided over what “total coverage denial of a claim” means under § 86.121, and we have obtained both favorable and adverse rulings on the question in Hillsborough and Orange Counties. No binding appellate decision has resolved the split on the merits.
We review peer review denials for patients treated 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
The insurer never paid us anything. Does it still need a valid peer review report?
Under the controlling appellate authority, no. Where there were no payments and the bills were rejected outright, the insurer may contest reasonableness, relatedness, and necessity under § 627.736(4)(b) without first obtaining a report meeting the § 627.736(7)(a) requirements. The report can still be challenged as evidence.
The insurer paid us for two months and then stopped. Is that different?
Substantially. That pattern is a withdrawal of payment of a treating physician, and § 627.736(7)(a) applies. The statutory requirements for a valid report are in play.
Can the insurer raise medical necessity years later?
Section 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. That is broad. It does not eliminate the separate constraints that apply to withdrawal of a treating physician’s authorization.
The insurer paid some dates of service and not others. Which is it?
That is a genuinely contested question and depends on the specifics — which providers, which codes, which dates, and what the carrier’s correspondence says it was doing. It needs to be looked at rather than assumed.
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 File and We Will Tell You Which One You Have
The payment history on a claim tells us more in five minutes than the denial letter tells you in five pages. Send us the explanation of benefits, the peer review report, and the carrier’s correspondence, and we will tell you whether this is a withdrawal or a denial, and what that means for the claim.
Call Licznerski Law, PLLC at 813-934-3519, email [email protected], or visit www.licznerskilaw.com.
Licznerski Law, PLLC — When Insurers Bet That You Won’t Fight, We Make Them Pay.