How Much is the PIP Fee Schedule Supposed to Pay?

How much does PIP pay for services?

PIP allows two times the amount of Medicare Part B (aka 200%). PIP pays 80% of that amount.

The link to Medicare’s fee schedule for Florida is at the bottom of this email.

The PIP law made Medicare rates in 2007 as the baseline. That means that if 2013 rates are less than 2007 rates then you go with 2007 rates. Medicare rates in 2007 are typically higher than 2012-2013 rates.

Also, the PIP law says that if a CPT code isn’t payable under Medicare then you would look to the Florida Work Comp fee schedule to see if it is payable. A good example is cold/hot packs (97010) which isn’t compensable under Medicare but is compensable under Work Comp. The link to the Work Comp fee schedule by clicking here.

After you follow the instructions below you will realize why some insurance companies pay different rates for the same service. It can be very confusing but hopefully I simplified it. If you have questions then feel free to call or email me.

DIRECTIONS TO FIND MEDICARE FEE SCHEDULE:

  • Go to: https://medicare.fcso.com/
  • Select Florida and Part B when the pop up appears.
  • Hover the mouse on “Popular Links” in the top left corner of the webpage and click on “fee schedule lookup page”.
  • Select “Medicare Physician and NonPhysician Practicioner Fee Schedule (MPFS)”
  • Select a Date of Service
  • Select your location
  • Enter a CPT Code

Which dollar amount do I choose from the list?

Figure out if you are a Facility or a Non-Facility. Figure out if you are Par vs. Non-Par?

What is Facility vs. Non-Facility?

A facility will usually be either a hospital or surgical center. If you are a doctor billing for services out of your office then you are usually going to pick the non-facility fee. If you are a doctor working in a hospital or surgical center then you are usually going to choose the facility fee.

What is Par vs. Non-Par?

If you are “par” then you “participating” and you accept assignment. If you are “non-par” then you don’t accept assignment and can balance bill the patient.

The primary differences are, 1) the fee that is charged, 2) the amount paid by Medicare and

the patient, and 3) where Medicare sends the payment. The primary similarities are, 1) the provider must bill Medicare directly, 2) there is the same annual deductible, and 3) a 20% co-insurance is applied to the charge. An easy to read source can be seen by clicking here.

What if a code isn’t allowed by Medicare or Work Comp? How much would PIP pay?
This is a quote directly from the PIP law:

“Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by the insurer.”

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