UPDATES TO TEFCA, IAS, AND THE FUTURE OF MEDICAL RECORD RETRIEVAL FOR ATTORNEYS AND PROVIDERS IS A FLORIDA PIP INSURER ALLOWED TO APPLY MEDICARE’S BUDGET NEUTRALITY ADJUSTMENT?
PICTURES OF OUR PERSONAL INJURY SUMMIT® IN FORT LAUDERDALE SUCCEEDING UNDER TORT REFORM PART 7 - THE ABSURD “BURDEN-SHIFT-SCARE” IN THE TRIAL COURTS APPEARS TO BE OVER
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From the Editor
WELCOME TO THE PERSONAL INJURY MAGAZINETM !
We're just entering the middle of summer, and we've already had two amazing Personal Injury Summits this year. If you were there, you likely left feeling inspired by the energy and with lots of strategies to implement in your office to grow your PI practice. It's very encouraging to see everyone's commitment to being the best they can be for their clients and witness the forging of powerful connections to push this industry forward. We can't wait to see you again at our next Personal Injury Summits in 2026!
As always, we'd like to recognize our loyal partners who came from all over the country to support our industry. Many of our partners provide critical contributions through expert presentations at the PI Summits, as well as articles in this magazine that will help you stay up to date on the latest affecting PI practices. We hope you enjoy this new edition and hope to get your feedback on any topics you'd like to see addressed in future issues!
Sincerely yours,
Angely C. Maria EDITOR IN CHIEF
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UPDATES TO TEFCA, IAS, AND THE FUTURE OF MEDICAL RECORD RETRIEVAL FOR ATTORNEYS AND PROVIDERS
By Tiffanny J. Anghel, MHA
In the legal world, especially in personal injury and medical malpractice, access to complete, timely medical records can make or break a case. For years, attorneys and medical providers have faced slow, fragmented, and expensive processes to retrieve medical records. That is rapidly changing with the federal rollout of TEFCA (Trusted Exchange Framework and Common Agreement) and the rise of Individual Access Services (IAS).
Under TEFCA, health data sharing is being standardized across the country through Qualified Health Information Networks (QHINs). These QHINs form a secure, interoperable “network of networks” where records can be shared between providers for treatment and care coordination, payers, and—with patient consent—third parties like attorneys and legal tech providers under the IAS use case.
The most transformative development for the legal industry is IAS, which empowers attorneys to retrieve a client’s medical records faster through federally supported infrastructure—if the client consents and their identity is verified to NIST’s IAL2 standard. Legal tech companies like YoCierge are leveraging this to build integrations with state-based entities that allow for rapid, compliant aggregation of records, cutting retrieval times from weeks to days.
Progress is already visible at the state level. YoCierge has gone live with New York, Delaware including surrounding states, and is actively onboarding Michigan’s network with several other states in conversations. These integrations mean that attorneys handling cases in these states can now initiate medical record retrievals that connect directly with states through a simple, consent-driven process and ID verification process.
Meanwhile, the new federal administration in Washington has doubled down on enforcing interoperability and expanding TEFCA's impact. The Department of Health and Human Services (HHS) and the ONC are providing additional funding and guidance for interoperability expansion, while emphasizing compliance
with the 21st Century Cures Act, which mandates that patients (and by proxy, their representatives) not be blocked from accessing health data.
Recent remarks from HHS officials suggest stronger oversight on information blocking enforcement and greater penalties for non-compliant health systems and vendors. This signals a federal commitment to not just building the infrastructure but ensuring it’s used. We saw that there was a little uncertainty with the future funding of the framework with the administration changing at the Whitehouse and feared that the government would not continue to support TEFCA, but due to new changes in the federal level administration, there continues to be strong advocacy to continue the progress made.
For attorneys and providers, the message is clear: interoperability is no longer optional—it’s here. And with TEFCA and IAS, the path to retrieving complete medical records, with patient consent, is more seamless than ever. This will allow the legal and medical industries to be able to support API integrations and interoperability more effectively for the greater good of the patient. ■
For more information about IAS, scan the QR code:
Tiffanny J. Anghel,
MHA HEAD OF PARTNERSHIPS YOCIERGE & YC API
envelope ta@ycapi.health phone-alt 862-209-0195
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SUCCEEDING UNDER TORT REFORM
the Trial Courts Appears to be
By Aaron Proulx, Esq.
This is the seventh article in a series that lights the way to success under Florida Tort Reform’s Section 768.0427. This article focuses on some recent conflicting trial court orders that address the question of which party has the burden to present the evidence to establish the reasonableness of the bill.
The conflicting orders center on the heart of the statute – Subsection (2)(b) – which states:
Evidence offered to prove the amount necessary to satisfy unpaid charges for incurred medical treatment or services shall include, but is not limited to, evidence as provided in this paragraph.
Four subsections within Subsection (2)(b) apply to the various scenarios regarding the availability and use of commercial health insurance and Medicare, and to the sale of medical bills. The statute then explains what evidence is admissible for each of those four situations. For example, admissible evidence in a Subsection (2)(b)(1) case is the amount that “health care coverage is obligated to pay.” Remember, there is a fifth subsection that is a catchall for any other evidence tending to establish reasonableness.
Between February 26 and April 16 of 2025, the five orders comprising the minority view concluded that the “shall” in the introductory paragraph of Subsection (2)(b) meant that to establish the damages portion of the prima facie case, the plaintiff had the burden to present the evidence in Subsections (2)(b)(1)-(4) depending on the type of case. Failure would result in a summary judgment or directed verdict. For example, a Subsection (2)(b)(1) plaintiff must present the amount that “health care coverage is obligated to pay.” Given that the statute expressly prohibits discovery and admissibility of health insurance contracts – where the amount the insurer is “obligated to pay” is found – this interpretation would render it impossible for a plaintiff to establish the prima facie case.
None of the prior articles in this series anticipated the rise of the minority view. This is because neither the title of the statute nor the plain language of the text remotely suggests that the legislature redefined the elements of the negligence tort or presented new burdens of proof in negligence cases. Such statutes do exist. Section 628.0427 is not one of them. Instead, the statute expressly addresses only discovery and admissibility.
Fortunately, the majority view – with nine orders (five of which were entered in May 2025) – came to this same inevitable conclusion. See, e.g., Beyenka v. Pyle, 2023-CA-009204 (4th Cir. Duval County, J. James Daniel) (“The word ‘admissible’ has never been used in the law to establish a burden of proof.”).
The orders establishing the majority view present a plethora of other reasons to reject the minority view. These include: (1) a statute can be interpreted to alter common law only when the statute is clear, but nothing in the statute alters the common law that the prima facie case is satisfied by a plaintiff’s own testimony that the bills are reasonable, (2) if a court interprets the statute as abrogating common law, then the statute would be unconstitutional-as-applied because statutes in derogation of common law must meet certain procedural requirements in the legislature, which this statute did not meet, (3) the minority view is contradicted by the existence of the “catchall” in Subsection (2)(b) (5), (4) to be consistent with the multiple examples of statutory construction cases wherein “shall include but is not limited to,” is used, the statute cannot be construed as a list of required evidence, and (5) The minority view renders the statute absurd because it requires a plaintiff to present unobtainable evidence (what “health care coverage is obligated to pay”) and unknowable evidence (the amount at which future bills “could be satisfied”) in order to avoid a directed verdict.
In short, while we cannot know, we can expect the minority view shortly to be diluted out of existence. We also can expect a district court, if called upon, to reject the minority view. ■
Aaron Proulx, Esq. THE DOCTOR’S LAWYER, PLLC.
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BURSTING THE PRESUMPTION BUBBLE: OVERCOMING EUO NO-SHOW CHALLENGES
By George A. David, Esq.
Many times insurance companies like to make medical providers believe that if the insured fails to appear to an Examination Under Oath (EUO) the medical provider will not get paid any medical bills. It is true that insurance companies have a statutory right to request an Examination Under Oath and most insurance policies set forth procedures specifying how the insurance company is to take an EUO.
What happens when the patient/insured fails to appear to an examination under oath? Is the medical provider’s chances of getting paid doomed? Not always. One thing that is often overlooked is that there must be more than just the insured failing to appear to an EUO for an insurance company to avoid paying medical bills to a medical provider.
When an insured/patient fails to appear to an EUO, there is a presumption that the insurance company is “prejudiced” or hurt, meaning that it cannot investigate the PIP claim. However, this presumption is what the law calls a “bursting bubble” presumption, meaning that the presumption can be shattered and no longer exist if the medical provider can present evidence that the insurance company’s investigation was not destroyed by the insured/patient not appearing to the EUO.
For example, if the insurance company has information already in its investigation arsenal to show that there is no coverage or answers questions the insurance company would have wanted to ask the insured/ patient at the EUO, then the presumption of prejudice bubble is burst and no longer exists. This can make the
The presumption of prejudice can be shattered if the medical provider can present evidence that the insurance company’s investigation was not destroyed.
insurance company’s examination under oath defense becomes invalid.
An experienced attorney should be able to find out if the presumption bubble is burst in an EUO no show case. Once this happens, then the medical provider can get paid its deserved PIP benefits owed to it. ■
George A. David, Esq.
GEORGE A. DAVID P.A
George A. David P.A.
We are the law firm that is not afraid of difficult cases. We handle all cases, including the more difficult cases such as where insurance companies deny claims because:
◦ $10,000.00 policy limits are exhausted
◦ Material misrepresentation
◦ Fraud
◦ Invalid reductions in medical bills
◦ Failure to appear to examinations (EUOs) under oath or “independent” medical examinations (IMEs)
We work with medical providers in EUO and IME requests from insurance companies. We also will co-counsel with personal injury attorneys in making a special appearance in scheduling and appearing to EUOs and IMEs. We are available to answer any PIP questions. Just call or email us.
George David represented insurance companies from 1991 up until 2001. Since 2001 George David has been representing medical providers in PIP suits. We know all the insurance companies’ tricks. We handle cases throughout Florida and have suits filed in the Tampa, Tallahassee and South Florida areas. Our main office is in Coral Gables.
IS A FLORIDA PIP INSURER ALLOWED TO APPLY MEDICARE’S BUDGET NEUTRALITY ADJUSTMENT?
By Christopher M. Tuccitto, Esq.
In the complex world of Florida Personal Injury Protection (PIP) claims, one issue that continues to spark legal debate is whether insurers may apply Medicare’s Budget Neutrality Adjustment (BNA) when determining reimbursements owed to medical providers. The short answer? No. Under current Florida law, a PIP insurer is not permitted to apply the BNA when reimbursing providers under the Medicare Part B Fee Schedule.
To understand this issue, we need to start with how Florida’s PIP statute works. Section 627.736(5)(a), Florida Statutes permits insurance carriers to limit payments to a percentage of the Medicare fee schedules, so long as the reimbursement does not fall below the 2007 Medicare Part B Non-Facility Participating Price. However, if treatment was provided in either Miami-Dade or Monroe Counties, reimbursement cannot fall below the slightly higher 2007 Medicare Part B Non-Facility Limiting Charge as held in Priority Medical Centers, LLC v. Allstate Ins. Co. In this framework, the Medicare Fee Schedule operates as a statutory minimum—or floor— not a ceiling, for provider reimbursement.
The Medicare Fee Schedule itself is based on a general formula that takes into account various factors like the Relative Value Units (RVUs) for physician work, practice expense (PE), and malpractice insurance, each adjusted by geographic indices (GPCIs), and then multiplied by a conversion factor (CF). This well-established formula ensures consistency and fairness in payments to providers.
However, Medicare, as a federal payer, occasionally inserts a Budget Neutrality Adjustor Value (BNAV) into this formula. This adjuster modifies the “Work RVU” component and is used strictly to control overall Medicare expenditures. The purpose is to balance the federal budget—not to change the actual RVU structure or suggest reductions for use by private insurers.
In fact, the Centers for Medicare and Medicaid Services (CMS) has been explicit about this. In a 2006 press release and subsequent rulemaking, CMS clarified that the BNA was designed solely for Medicare’s internal fiscal use. CMS even cautioned that the adjusted formula should not be relied upon by private payers to determine payment rates. This was a deliberate move
to protect the integrity of the Medicare Fee Schedule, recognizing that many private insurers—like PIP carriers—rely on it to determine reasonable charges.
Florida courts have reinforced this position. In Nationwide Mutual Fire Ins. Co. v. AFO Imaging, Inc., the Second DCA held that the Medicare Part B participating physician’s schedule is the operative benchmark. And more recently, in Priority Medical Centers, LLC v. Allstate Ins. Co., the Third DCA found that a PIP insurer’s use of the BNA to reduce payments fell below the statutorily mandated minimum, resulting in an underpayment and breach of contract.
The legal principle is clear: while PIP insurers may elect to pay benefits based on a percentage of Medicare rates, they must use the unadjusted Medicare Part B Fee Schedule. They are not Medicare, nor are they acting under Medicare’s statutory mandates. Therefore, they cannot adopt payment reductions—like the BNA— intended solely for federal budgeting purposes.
Allowing the use of the BNA by PIP insurers would effectively let them pay less than the statutory floor established by the Legislature, contradicting both the spirit and the letter of Florida’s No-Fault law. As noted in SOCC, P.L. v. State Farm, the statute incorporates a specific Medicare fee schedule, not a version modified for federal budgeting goals.
In sum, Florida PIP insurers are bound by the Medicare Fee Schedule’s structure as it existed for the applicable year—without the Budget Neutrality Adjustment. Any attempt to do otherwise risks violating statutory requirements, underpaying providers, and exposing insurers to liability for breach of contract. ■
