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 statutory maximum reimbursement allowances in section 440.13(12) to 175% of Medicare for physician services and 210% for surgical procedures. Good news on paper. The 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 becomes a rate change in payment only after every carrier, self-insurer, TPA, and bill-review vendor loads it into their systems. Some load late. Some load wrong. Payments that keep running on the old assumptions look completely normal on the remittance. It's the classic renegotiated-rates-never-loaded pattern, except this time it's statewide and hits every carrier at once.
Workers' comp makes it harder to see, too. Florida doesn't 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 through a portal, which usually means it sits outside whatever automated payment checking a practice runs on its commercial remittances. Underpaid WC lines are simply harder to spot.
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 biggest exposure. But the 175% physician rate applies to the office visits and injections every treating specialty bills, so nobody is exempt.
The 45-day clock: the shortest fuse in Florida
WC reimbursement disputes don't 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) has to attach all supporting documentation, since an incomplete filing risks dismissal, with copies to the carrier by certified mail. DFS issues a written determination within 120 days after it receives all documentation.
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 on a written request for authorization for referral for medical treatment means the carrier consents to the medical necessity of that treatment (§440.13(3)(d)); the higher-value services in §440.13(3)(i) need express authorization unless the carrier fails to respond within ten days. That's a strong lever on no-auth denials; more in the CO-197 note.
One boundary
- 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. EOBRs older than about 45 days from receipt are largely past the petition path, however clear the shortfall. Commercial underpayments are different; they stay open for 12 months under Florida's statutory window. So the discipline here is monitoring. Check each EOBR against the 175%/210% MRAs as it arrives, and petition inside the window. Start today and every claim from today forward is protected. Wait, and the difference keeps going to the carrier.