XL Specialty Insurance Challenges Florida Rule Governing ‘Usual and Customary’ Workers’ Compensation Medical Reimbursement Charges

Jan 11, 2017


Calling it an “unconstitutional taking” that Florida hospitals have the ” . . . unfettered right to set whatever outpatient prices they want without any due process safeguards to the payers,” XL Specialty Insurance has challenged the validity of Rule 69L-7.501, F.A.C., which governs Florida Workers’ Compensation Reimbursement Manual for Hospitals.

After disputing what it termed a “700 percent markup” on a hospital charge in a workers’ compensation case, XL decried “the current scheme (which) gives the hospitals the right to set the price of the services, but also deprives the payors of the ability to challenge the amount of any of the facility’s charges; a deprivation of all due process rights for the payor and an unlimited and unfettered grant of power to the hospitals to charge whatever they want, no matter how unconscionable, and the State enforces those charges against the defenseless payor.”

An administrative hearing had been set in the matter (DOAH Case 16-006426RX) for early December 2016, but XL voluntarily withdrew its petition in advance of the Rule validity challenge filed with the Florida Department of Financial Services on January 6, 2017.

In its petition, XL noted that the 2003 amendment of s. 440.13 (12)(a), F.S. requires reimbursement to be based on “usual and customary charges,” which it argued refer to those charged on a regional basis, not by an individual hospital.  The 1992 version of the law specified “the hospital’s usual charge,” but the updated statute omitted reference to a billing facility.


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