Two Paths for Florida Drivers

PROPOSED AMENDMENT TO FLORIDA STATUTES
RELATING TO MEDICAL NECESSITY DETERMINATIONS

Section 1. Independent Medical Necessity Determination (IMND)

(a) Every determination of medical necessity for continued care following the initial 
    course of treatment (as defined by the operation of law) shall be based on a direct 
    medical examination of the claimant.

PROPOSED PRE-SESSION AMENDMENT
Independent Medical Necessity Determination Safeguard
Consumer Protection & Cost Certainty Measure
To be added to PIP Repeal / Motor Vehicle Insurance Reform Legislation – 2026 Session

Section __. Independent Medical Necessity Determination; Reimbursement Safeguards.

(1) Legislative Purpose and Intent.
The Legislature finds that following repeal of Personal Injury Protection (PIP), Florida motorists require a neutral, medically grounded safeguard to ensure that determinations of injury severity and continued medical necessity are made by independent medical professionals rather than by treating providers with financial interests or by insurers through non-clinical review processes.
This section establishes an Independent Medical Necessity Determination to:
	•	Protect consumers from unnecessary or prolonged treatment;
	•	Prevent paper-only claim denials;
	•	Reduce litigation escalation; and
	•	Provide cost predictability without limiting access to medical care.
Nothing in this section authorizes an insurer to order, direct, or control medical treatment.

(2) Definitions.
For purposes of this section:
(a) “Independent Medical Necessity Determination” or “IMND”
means a medical evaluation conducted by a qualified, independent medical professional solely to determine:
	1	Injury severity; and
	2	Whether continued treatment is medically necessary for reimbursement purposes.
(b) “Initial course of care”
means treatment rendered within the first 30 days following the motor vehicle accident or the first 12 treatment visits, whichever occurs first.
(c) “Independent medical determination”
means a written medical finding resulting from an Independent Medical Necessity Determination.

(3) Requirement by Operation of Law.
An Independent Medical Necessity Determination is required by operation of law, and not by insurer request or prescription, when:
(a) Treatment extends beyond the initial course of care; or
(b) Injury severity, threshold injury status, or continued medical necessity is disputed for reimbursement purposes.

(4) Authorized Evaluators and Method of Examination.
(a) An Independent Medical Necessity Determination may be performed by:
	1	A physician licensed under chapter 458 or 459, Florida Statutes;
	2	A physician assistant licensed under chapter 458 or 459, Florida Statutes; or
	3	An advanced practice registered nurse licensed under chapter 464, Florida Statutes.
(b) The determination may be conducted in person or via telemedicine as defined in s. 456.47, Florida Statutes.
(c) The evaluating professional must have no financial, employment, referral, or treatment relationship with:
	1	The treating provider whose care is under review; or
	2	The claimant.

(5) Initiation of Independent Medical Necessity Determination.
An Independent Medical Necessity Determination may be initiated by:
(a) The claimant;
(b) A treating provider other than the provider rendering ongoing care; or
(c) By operation of law when reimbursement beyond the initial course of care is sought.
An insurer may not order, prescribe, select, or compel an Independent Medical Necessity Determination.

(6) Nature and Scope.
(a) The Independent Medical Necessity Determination is limited to determining:
	1	Injury severity; and
	2	Whether continued treatment is medically necessary for reimbursement purposes.
(b) The determination:
	1	Does not constitute treatment or ongoing care;
	2	Does not establish a provider-patient relationship for treatment purposes; and
	3	Is an independent medical claims safeguard only.
(c) Peer review, utilization review, record review, or paper-only review does not satisfy the Independent Medical Necessity Determination requirement.

(7) Compensation.
(a) Total compensation for an Independent Medical Necessity Determination shall not exceed $300, which constitutes the maximum allowable and exclusive charge, inclusive of all professional, administrative, technical, telemedicine, record review, and reporting services.
(b) The fee:
	1	Shall be paid directly by the insurer;
	2	Shall not be billed to the insured or claimant;
	3	Shall not be subject to balance billing; and
	4	Shall not reduce policy limits or claimant benefits.
(c) No additional compensation may be sought under any other provision of law or legal theory.

(8) Effect on Reimbursement.
(a) If an Independent Medical Necessity Determination finds that continued treatment is not medically necessary, no insurer is required to reimburse for treatment rendered after the date of the determination, regardless of provider type.
(b) For reimbursement purposes, chiropractic, rehabilitative, or passive therapy services rendered after a finding of no medical necessity are non-compensable, unless a subsequent independent medical determination establishes continued necessity.

(9) Absence of Independent Medical Determination.
(a) In the absence of an Independent Medical Necessity Determination establishing continued medical necessity, reimbursement is not required for treatment rendered after the initial course of care.
(b) A treating provider’s own determination of medical necessity does not establish reimbursement eligibility beyond the initial course of care.
(c) Treatment may continue at the election of the claimant; however, reimbursement is limited to services rendered prior to satisfaction of this section.

(10) Prohibited Conduct.
(a) A treating provider may not condition care on the outcome of an Independent Medical Necessity Determination.
(b) An evaluating professional or entity may not be compensated based on claim outcome, volume, or coverage determination.
(c) A treating provider may not extend or continue treatment for reimbursement purposes based solely on the provider’s own medical necessity determination following a finding to the contrary.
(d) Treatment records, affidavits, or opinions generated after a finding of no medical necessity may not be used to establish retroactive reimbursement eligibility, absent a new qualifying medical event.

(11) Rule of Construction.
Nothing in this section shall be construed to:
(a) Limit access to medical care;
(b) Restrict a claimant’s right to contest liability or damages;
(c) Authorize insurers to direct or control medical treatment; or
(d) Convert an Independent Medical Necessity Determination into a treating medical service.

(12) Applicability.
This section applies to all motor vehicle accident claims arising on or after the effective date of this act.

                    

Section X. Emergency Medical Condition Transparency Requirements

(1) Legislative Intent.
It is the intent of the Legislature to enhance transparency, integrity, and consumer confidence in Emergency Medical Condition (EMC) determinations made under Florida motor vehicle insurance law by requiring objective disclosure, independence, and public accountability without restricting access to medically necessary care.

(2) Written EMC Determination and Disclosure.
Any Emergency Medical Condition determination relied upon for purposes of benefit eligibility or reimbursement shall be documented in a written medical determination that includes:
(a) The clinical basis supporting the determination;
(b) The credentials and licensure of the evaluating medical professional;
(c) The date, modality, and method of evaluation, including whether the determination was made in person or via telemedicine; and
(d) A statement affirming compliance with the independence requirements of this section.

(3) Independence Requirement.
An EMC determination shall be made by a licensed medical professional who has no financial interest, referral relationship, or ownership interest with any treating provider, diagnostic entity, law firm, or insurer involved in the claim, other than compensation for the evaluation itself.

(4) Prohibition on Paper-Only Determinations.
An EMC determination may not be based solely on a paper or records review. The evaluating medical professional must conduct a direct patient evaluation, either in person or through synchronous telemedicine, consistent with applicable standards of care.

(5) Public Transparency and Consumer Access.
The Office of Insurance Regulation shall maintain or designate a publicly accessible transparency resource providing educational information regarding EMC determinations, consumer rights, evaluator independence standards, and complaint mechanisms. Such resource shall be made available online and may be accessed at https://www.emctransparencybill.com or any successor site designated by the office.

(6) No Retroactive Justification.
Once an EMC determination is issued finding that a condition does not meet the statutory definition of an Emergency Medical Condition, such determination may not be retroactively altered or justified through subsequent documentation absent new clinical findings obtained through a qualifying medical evaluation.

(7) Enforcement.
Failure to comply with the transparency, independence, or disclosure requirements of this section shall render the EMC determination unenforceable for benefit eligibility or reimbursement purposes and may constitute grounds for administrative action as provided by law.