Notes on payer behavior
Florida workers' comp now pays 175–210% of Medicare. Is your practice getting it?
On January 1, 2025, Florida workers' comp quietly became one of the better-paying lines on many fee schedules. SB 362 raised the maximum reimbursement allowances in the state's 2024 Reimbursement Manual to 175% of Medicare for physician services and 210% for surgical procedures. The open question for any practice treating work injuries is simpler than the statute: are the carriers actually paying it?
Why new rates mean new underpayment
A rate change on paper only becomes a rate change in payment after every carrier, self-insurer, TPA, and bill-review vendor loads it into their systems. Some load late; some load wrong. Payments that continue at the old assumptions look completely normal on the remittance — the classic renegotiated-rates-never-loaded pattern, except this time it is statewide and affects every carrier at once.
Workers' comp compounds the visibility problem: Florida does not require WC carriers to send standard electronic remittances (X12 835s). WC payment detail arrives as an EOBR — an explanation of bill review — on paper or a portal, which usually means it sits outside whatever automated payment checking a practice runs on its commercial remittances. Underpaid WC lines are structurally harder to see.
Who this touches
Any specialty that treats work injuries: occupational medicine clinics, orthopedics and hand surgery, pain management, physical therapy and physiatry, spine, and the general surgeons and ENT or dermatology practices that see the occasional workplace laceration or exposure. The surgical MRA at 210% of Medicare makes procedure-heavy specialties the largest exposure — but the 175% physician rate applies to the office visits and injections every treating specialty bills.
The 45-day clock — the shortest fuse in Florida
WC reimbursement disputes do not go through the carrier's appeal process. Florida runs one uniform state regime for every carrier and TPA: a petition to the Department of Financial Services under §440.13(7) and Rule 69L-31, filed within 45 days of receipt of the EOBR. The petition (Form DFS-F6-DWC-3160-0023) must attach all supporting documentation — an incomplete filing risks dismissal — with copies to the carrier by certified mail. DFS issues a written determination within 120 days.
The 30-day waiver rule is the lever. Once a petition is filed, the carrier must respond within 30 days with substantiating documentation — or it waives all objections (§440.13(7)(b)). Few payment-dispute regimes anywhere hand the provider a default rule this strong.
The other clocks worth knowing
- Carrier bill handling: pay, adjust, disallow, or deny within 45 days of receiving the bill (§440.20(2)(b)).
- Authorization: the carrier must respond to an authorization request by the third business day — silence is authorization by operation of law, and it forfeits the carrier's medical-necessity contest (§440.13(3)). A strong lever on no-auth denials; more in the CO-197 note.
Two boundaries
- Services under a certified §440.134 managed-care arrangement cannot use the DFS petition — they go through the arrangement's grievance process. Few of these remain, but the petition form asks, so screen per payer.
- Compensability denials — the carrier disputing that the injury is covered at all — are Judge of Compensation Claims territory, not DFS reimbursement disputes. Route those to counsel.
What 45 days means operationally
The short clock makes WC recovery forward-looking. Trailing EOBRs older than about 45 days from receipt are largely beyond the petition path, however clear the shortfall — unlike commercial underpayments, which stay open for 12 months under Florida's statutory window. The practical discipline is monitoring: check each EOBR against the 175%/210% MRAs as it arrives, and petition inside the window. A practice that starts checking today protects every claim from today forward; the one that waits keeps donating the difference.