ClaimCarePro

Florida PIP Fee Schedule Calculator: 200% of Medicare, Then 80%

By Jacob Greenberg

Short answer: for most office services, Florida PIP pays 80% of 200% of the Medicare Part B participating amount for your CPT code, locality and service year, so 160% of Medicare. An unmet deductible comes off first, the payment stops at the benefits left ($10,000 with an emergency medical condition, $2,500 without), and a billed charge below the schedule is paid at 80% of the charge. The calculator below runs all of it for one line and cites the Fla. Stat. § 627.736 subsection behind every step.

Florida PIP fee schedule calculator

One line at a time. Look up the Medicare amount for your CPT code, locality and service year in the CMS Physician Fee Schedule lookup (use the participating, non-facility or facility amount that matches where you treated).

Rule: 200% of the Medicare Part B participating physicians fee schedule (§ 627.736(5)(a)1.f.(I))

All units together.
The schedule can never drop below 2007, § 627.736(5)(a)2.
Insurers must offer $250, $500 and $1,000 deductibles (§ 627.739(2)). Enter 0 if none.
$10,000 with an EMC, $2,500 without, minus what has been paid.
From the EOB. Shows the underpayment, if any.

Enter the amount, units and billed charge to see the PIP payment.

An estimate, not legal advice. The insurer may pay on this schedule only if the policy gave notice that it limits payment to the schedule (§ 627.736(5)(a)5). Use the Medicare amount in effect on March 1 of the service year, March 1 through the end of February (§ 627.736(5)(a)2). Insurers may also apply Medicare coding policies and modifiers (§ 627.736(5)(a)3).

The schedule of maximum charges, by type of service

§ 627.736(5)(a)1. sets a different ceiling for each kind of care. The insurer may limit payment to 80% of the ceiling. Pick the row that matches the claim:

Florida PIP schedule of maximum charges under 627.736(5)(a)1.
Type of serviceSchedule maximum§ 627.736
Office and professional services (physician, chiropractic, PT)200% of the Medicare Part B participating physicians fee schedule(5)(a)1.f.(I)
Ambulatory surgical center, clinical laboratory200% of Medicare Part B(5)(a)1.f.(II)
Durable medical equipment200% of the Medicare Part B DMEPOS fee schedule(5)(a)1.f.(III)
Emergency transport and treatment (ch. 401)200% of Medicare(5)(a)1.a.
Hospital emergency services75% of the hospital's usual and customary charges(5)(a)1.b.
Physician or dentist emergency care in a hospitalUsual and customary charges in the community(5)(a)1.c.
Hospital inpatient, non-emergency200% of the Medicare Part A prospective payment for that hospital(5)(a)1.d.
Hospital outpatient, non-emergency200% of the Medicare Part A APC for that hospital(5)(a)1.e.
Not reimbursable under Medicare Part BWorkers' compensation maximum reimbursable allowance (s. 440.13)(5)(a)1.f.

Care that is reimbursable under neither Medicare nor workers' compensation does not have to be paid at all (§ 627.736(5)(a)1.f.). Massage therapy and acupuncture are excluded from PIP medical benefits entirely (§ 627.736(1)(a)5.).

The order of operations

Run the steps in this order. Getting the order wrong is how a correct EOB looks wrong, and the reverse.

  1. Find the base amount for the service year and locality. For Part B services, use the higher of that and the 2007 Part B amount (§ 627.736(5)(a)2.).
  2. Apply the schedule for the row above, times the units.
  3. Compare to your billed charge. If you billed less, the billed charge is used (§ 627.736(5)(a)5.).
  4. Subtract the unmet deductible. It applies to 100 percent of the expense, before the 80% (§ 627.739(2)).
  5. Take 80% of what is left (§ 627.736(1)(a) and (5)(a)1.).
  6. Cap it at the PIP medical benefits remaining (§ 627.736(1)(a)3.-4.).

Example with made-up inputs (not a real Medicare rate): a $50.00 Part B amount, one unit, billed at $150.00, no deductible. Schedule: $100.00. PIP pays $80.00. The $20.00 coinsurance may go to the patient or other coverage; the $50.00 billed above the schedule may not be billed to the patient (§ 627.736(5)(a)4.). Add a $250 unmet deductible and the whole $100.00 goes to the deductible: PIP pays $0.00 on that line.

Which Medicare year: the March 1 rule and the 2007 floor

PIP does not use the calendar year. § 627.736(5)(a)2. fixes the Medicare schedule in effect on March 1 of the service year, and the service year runs March 1 through the end of February. A January 2027 date of service is priced on the schedule in effect March 1, 2026. A mid-year Medicare change does not move it. For Part B services the amount can never be lower than the 2007 Part B amount, so when a code has lost value since 2007, the 2007 figure is the one to use. Get both from the CMS Physician Fee Schedule lookup, choosing the Florida locality where you treated.

When your billed charge is lower than the schedule

§ 627.736(5)(a)5. lets the insurer pay on a charge below the schedule. In Allstate Insurance Co. v. Revival Chiropractic, 385 So. 3d 107 (Fla. 2024), the Florida Supreme Court held the insurer may pay 80% of that lower charge. The practical rule: check that your PIP charge for every code is at least 200% of the current Medicare amount. A fee sheet set years ago can sit under the schedule and lose money on every visit.

The policy has to elect the schedule

An insurer may pay on the schedule only if the policy gave notice, at issuance or renewal, that payment may be limited to it (§ 627.736(5)(a)5.); an office-approved policy form satisfies that. If the policy does not elect it, the reasonableness standard in § 627.736(5)(a) governs instead, and this calculator does not apply. Ask the adjuster which method the policy uses before you dispute a number.

What the insurer can and cannot do to the number

  • Can: apply Medicare coding policies and payment methodologies, including modifiers and multiple-procedure rules (§ 627.736(5)(a)3.).
  • Cannot: apply Medicare or workers' compensation limits on the number of treatments, or refuse a licensed provider because Medicare would not pay that discipline for the code (§ 627.736(5)(a)3.).

When the EOB does not match

Back-calculate the base the insurer used: paid ÷ 0.80 ÷ 2 ÷ units. Compare it to the correct service-year amount for your locality. The usual causes of a gap:

  • Wrong year or locality. A calendar-year schedule used instead of the March 1 one, or the wrong Florida locality.
  • Missed 2007 floor on a code that has lost value since 2007.
  • A coding adjustment (modifier or multiple-procedure reduction). Legitimate if it follows Medicare policy; check the remark codes.
  • Benefits exhausted or EMC not documented, so the $2,500 limit was applied.

One short line is worth a call. The same short pay across a carrier's claims is worth a re-pricing pass and, if it is not fixed, a pre-suit demand letter under § 627.736(10). Where these underpayments come from is covered in Florida PIP underpayments under 627.736.

Getting underpaid PIP lines paid

ClaimCarePro, based in Clearwater, works aged and underpaid claims, Florida PIP included, on a 10% contingency: we are paid only on what we recover, and nothing if nothing is recovered. Ongoing PIP billing is 6% of collections with a $1,000 monthly minimum, month-to-month. Both prices are on the pricing page. Run your last month of auto-injury EOBs through the calculator; if the underpayment line keeps showing up, ask for a free A/R audit and we will look at the rest.

More on PIP: the PIP billing guide, PIP billing services, how to start a PIP practice in Florida and medical billing services.

Frequently asked questions

How do you calculate the Florida PIP fee schedule?

For most office and professional services: take the Medicare Part B participating physician fee schedule amount for the CPT code, locality and service year, multiply by 2 (the 200% schedule in Fla. Stat. 627.736(5)(a)1.f.), multiply by the units, then multiply by 0.80. Subtract any unmet deductible before the 0.80 step, and stop at the benefits remaining.

Does PIP pay 80% of 200% of Medicare?

Yes, for services on the Medicare Part B physician fee schedule, when the policy elects the schedule. 627.736(5)(a)1. lets the insurer limit reimbursement to 80 percent of the schedule of maximum charges, and the schedule for most professional services is 200% of Medicare Part B. That nets 160% of the Medicare amount.

Which Medicare year do Florida PIP insurers use?

The Medicare fee schedule in effect on March 1 of the service year, for the area where care was given. The service year runs March 1 through the end of February (627.736(5)(a)2.). For Part B services it can never be lower than the 2007 Part B amount.

Can the insurer pay 80% of my billed charge instead of the schedule?

If your billed charge is lower than the schedule amount, yes. 627.736(5)(a)5. lets the insurer pay on the charge submitted, and the Florida Supreme Court held in Allstate v. Revival Chiropractic (2024) that the insurer may pay 80% of it. Billing below 200% of Medicare leaves money unpaid.

Can I bill the patient for the difference?

Not for the amount above the schedule. Under 627.736(5)(a)4., when the insurer limits payment to the schedule, the provider may not bill the insured more, except the coinsurance and amounts over the policy limits.

What is the PIP limit without an emergency medical condition?

$2,500. Medical benefits reach $10,000 only when a qualifying provider (MD, DO, dentist, PA or APRN) determines an emergency medical condition (627.736(1)(a)3.-4.).

What if the auto policy does not elect the fee schedule?

The insurer may limit payment to the schedule only if the policy gave notice at issuance or renewal (627.736(5)(a)5.). Without it, the charge is judged on reasonableness under 627.736(5)(a): usual and customary charges, community reimbursement levels and fee schedules are all considered.

Educational information about billing mechanics, not legal advice. Statute text verified October 16, 2026 against the 2026 Florida Statutes; check the current text before relying on it.

Related guides