How to Start a PIP Medical Practice in Florida: Licensing, EMC, Billing and a 90-Day Launch Plan

Short answer: form a Florida entity, confirm whether its ownership lets it bill PIP without an AHCA Health Care Clinic license (Fla. Stat. 627.736(5)(h)), line up a provider who can make Emergency Medical Condition (EMC) determinations, and build intake and billing around four clocks: 14 days to first care, 21 days for a notice of initiation of treatment, 35 days to bill, and 30 days for the insurer to pay.

A PIP practice treats people hurt in Florida car crashes and bills their auto insurer under Personal Injury Protection, 627.736. The clinical work looks like any other practice. The business rules do not. Most of them date from HB 119 (2012), which took effect for most purposes on January 1, 2013 and rewrote who may bill PIP, who may determine an EMC, and which clinics must be licensed.

This guide covers administrative workflow only, not medical or legal advice. Statutes change. Every rule below cites the section it comes from, so you can check the current text of 627.736 and Chapter 400, Part X before you file anything.

Who is this guide for?

• Chiropractors opening their own PIP office, who need an EMC partner.
• Physicians (MD/DO) adding auto-injury care to an existing practice.
• Physical therapists, APRNs and other licensees who want to bill PIP and need to know whether they need a clinic license.
• Investors and managers who are not licensed practitioners and must run a licensed clinic.

Each of these owners faces different rules. The tables below are sorted so you can find your row.

What is a PIP practice, and which patients qualify?

A PIP practice treats auto-accident patients whose medical bills are paid first by their own Florida PIP coverage, regardless of fault. PIP pays 80% of reasonable expenses for medically necessary care, up to the policy limit (627.736(1)(a)).

The rule that shapes everything: initial services must be provided within 14 days after the motor vehicle accident (627.736(1)(a)). A patient who first seeks care on day 15 has no PIP medical benefits. Your front desk must capture the accident date before the first visit is booked.

Who may provide initial and follow-up care

A physical therapist cannot provide initial services. A PT practice depends on a referral from a listed initial provider, and the referral belongs in the chart.

What entity and licensing do I need?

You need a Florida entity, a type 2 NPI, active professional licenses, and either ownership that 627.736(5)(h) exempts or an AHCA Health Care Clinic license. Get this wrong and every bill can be unlawful.

The basic setup

• Entity. Form a Florida LLC or professional corporation through Sunbiz. Get an EIN.
• NPI. Each clinician needs a type 1 NPI. The practice needs a type 2 NPI with a taxonomy that matches what you do.
• Professional licenses. Every treating provider holds an active Florida license. The license number goes on every PIP claim form (627.736(5)(d)).

The PIP trap in the clinic exemption

Florida's Health Care Clinic Act is Chapter 400, Part X. Section 400.9905(4)(g) exempts many practices wholly owned by licensed practitioners. For PIP, that general exemption is not enough. Under 627.736(5)(h), an entity excluded from the clinic definition is deemed a clinic and must be licensed to bill PIP, unless it fits one of a short list.

One non-family investor can move you from exempt to licensed. A Florida health care attorney should review the structure before you sign a lease. Re-test it any time an owner, location or management agreement changes.

What if I need a clinic license?

A licensed clinic has two extra hurdles for PIP:

1. Licensure and a medical director. AHCA licenses each location, and the clinic must appoint a medical director or clinic director (400.9935). Apply through AHCA's Health Care Clinic unit. Check AHCA for current fees, background screening and inspection steps.
2. The follow-up conditions. For follow-up care, 627.736(1)(a)2 lists a licensed clinic only if it is accredited by a recognized accrediting organization, or if it has a medical director licensed under Chapter 458, 459 or 460, has been licensed continuously for more than three years (or is publicly traded), and offers at least four listed specialties. A brand-new clinic cannot meet the three-year test, so accreditation is usually the path. Confirm with your attorney how this applies to you.

Exempt practices can ask AHCA for a certificate of exemption. Keep it, and your written ownership analysis, ready for insurers who ask.

What the medical director signs for

Under 400.9935(1), the medical director or clinic director must, among other duties:

• Post a sign identifying the director where patients can see it.
• Confirm every practitioner holds an active, unencumbered Florida license and works within scope.
• Review every patient referral contract the clinic signs.
• Serve as records owner and keep record-keeping and adverse-incident reporting current.
• Systematically review clinic billing for fraudulent or unlawful charges, and act at once on any problem found.
• Not refer patients to the clinic if it performs MRI, static X-rays, CT or PET.
• Post a schedule of charges for at least the 50 most frequent services.

AHCA rule 59A-33.013 also caps one director at five clinics, 200 combined staff, and 200 miles between clinics. A director who never reviews billing is a liability. Under 400.9935(3), charges by a clinic operating in violation of Part X are unlawful, noncompensable and unenforceable.

What is an EMC, and who can determine it?

An Emergency Medical Condition determination is the difference between $10,000 and $2,500 in PIP medical benefits. Under 627.736(1)(a)3, benefits can reach $10,000 if a qualifying provider determines the patient had an EMC. Under (1)(a)4, they are limited to $2,500 if a provider determines there was none.

The statute defines an EMC as a condition with acute symptoms severe enough, including severe pain, that lack of immediate care could reasonably be expected to cause serious jeopardy to health, serious impairment of bodily functions, or serious dysfunction of an organ or body part (627.732(16)).

Who may determine an EMC

This is why chiropractic PIP practices bring in a part-time MD, DO, PA or APRN. Only a listed provider can unlock the $10,000 level.

What happens with no EMC on file

The statute sets the $2,500 limit when a provider finds no EMC. Florida appellate courts have applied the same limit when no determination was made at all. Insurers generally stop at $2,500 until a qualifying determination is in the file. The statute does not require the determination within the 14 days, but waiting risks the benefits being spent at the lower limit.

The EMC and intake workflow

An EMC that is not written down does not exist for billing. The determination should name the provider, license type, date and finding.

Do I need credentialing or enrollment with auto insurers?

No. Auto insurers are not health plans, so PIP billing does not require payer enrollment. You bill the carrier directly on a CMS-1500 (or UB-04 for facilities) with your NPI and professional license number (627.736(5)(d)). Expect requests for your W-9, licenses, and clinic license or exemption certificate.

Credentialing still matters for two reasons:

• Non-PIP patients. Medicare, Medicaid and commercial plans each require enrollment before you bill them in network.
• Exhausted PIP. Once the limit is used, remaining bills may go to the patient's health plan, which is harder if you are not enrolled.

Keep CAQH ProView complete, enroll in Medicare through PECOS, and use the Florida Medicaid portal. Credentialing timelines vary by payer.

How does the PIP fee schedule work?

Insurers may limit payment to 80% of the schedule of maximum charges in 627.736(5)(a)1. For most office-based services, that schedule is 200% of the Medicare Part B participating physician fee schedule. The insurer's policy must include a notice electing the schedule for the limit to apply (627.736(5)(a)5).

Three details catch new practices:

• Which year's Medicare schedule. The schedule in effect on March 1 of the service year controls (627.736(5)(a)2).
• The 2007 floor. Payment may not be less than the 2007 Medicare Part B allowable for the same service (627.736(5)(a)2).
• No Medicare utilization limits. Insurers may not apply Medicare or workers' compensation visit-count limits to PIP (627.736(5)(a)3).

Price your codes with the Florida PIP fee schedule calculator guide.

What deadlines does a PIP practice live by?

Practices miss the 35-day window most. Bill weekly. If the patient gave you the wrong insurer, (5)(c) gives you 35 days from learning the correct one; document when you learned it.

What are the common ways new PIP practices lose money?

• No EMC on file. Payments stop at $2,500.
• Day-15 patients. The first visit came too late, and nothing after it is payable under PIP.
• Wrong ownership for PIP. An exempt structure under 400.9905 that is not exempt under 627.736(5)(h). Insurers can deny every claim and sue to recover past payments.
• Missing D&A forms or visit logs. A bill that does not substantially meet the form rules need not be paid (627.736(5)(b)1d).
• Late bills. Outside 35 days, with no 21-day notice sent.
• Follow-up without a referral. Or care by a provider type not listed in (1)(a)2.
• Upcoding or unbundling. Insurers need not pay those charges and may correct codes after contacting you (627.736(5)(b)1e).
• Shared limit. Every provider who treats the patient draws from the same PIP limit. When it is paid out, later bills go unpaid unless another payer or an LOP covers them.
• Missed IMEs and records requests. A patient who unreasonably skips an insurer's exam can lose later benefits (627.736(7)). Records requests under (6)(b) need a sworn response.
• Fee schedule reductions applied wrong. See Florida PIP underpayments under 627.736.

For overdue claims, see the Florida PIP demand letter guide. For the full billing workflow, see the personal injury and PIP billing guide.

How do letters of protection and attorneys fit in?

A letter of protection (LOP) is an attorney's written promise that your bill will be paid from the patient's settlement. It covers care beyond the PIP limit, or care PIP will not pay. It is also slow money: you are paid when the case resolves, so plan cash flow around it.

• Put every LOP in writing, signed by the attorney and patient.
• Bill PIP first and on time. The LOP covers the balance; it does not replace timely PIP billing.
• Keep referral arrangements inside Florida's patient-brokering and anti-kickback laws. The 627.736(5)(e) form has the patient confirm they were not solicited. Your attorney should review any written arrangement, and a licensed clinic's medical director must review referral contracts.

Details are in our guide to PIP and letter of protection billing in Florida.

What is the 30/60/90-day launch checklist?

Where does ClaimCarePro fit?

ClaimCarePro handles PIP and personal injury billing for Florida practices. Ongoing PIP billing is 6% of collections with a $1,000 monthly minimum; only the aged A/R recovery track uses a 10% contingency. We bill inside the 35-day window, send the 21-day notice, track EMC status and benefit ceilings per patient, apply the 627.736 fee schedule, and send 627.736(10) demand letters when insurers pay late or short.

We also handle credentialing for your non-PIP payers, priced per application, so your Medicare, Medicaid and commercial patients are covered when PIP runs out. Our team brings 30+ years combined in medical billing. To talk through your setup, contact ClaimCarePro.

Frequently asked questions