By: Carlos Arce

Florida has enacted new statewide requirements governing the timely refund of patient overpayments by both licensed health care facilities and individual health care practitioners. The legislation establishes uniform standards, creates enforcement mechanisms, and becomes effective January 1, 2026.

The new law is intended to strengthen patient financial protections and ensure consistent refund practices across the health care system. Providers should begin preparing now to operationalize these requirements.

Health Care Facilities: New Section 408.12, Florida Statutes

Newly enacted section 408.12, Florida Statutes, applies to licensed health care facilities that tender charges for reimbursement. Under the statute, a facility must refund any patient overpayment no later than 30 days after the facility determines that an overpayment was made.

For purposes of the statute, a facility “tenders charges for reimbursement” when it files a claim with:

· A government-sponsored program; or

· A private health insurer or health maintenance organization

for services rendered to a patient.

Statutory Exclusions

Section 408.12 does not apply to patient overpayments that are governed by existing insurer and HMO payment statutes, including:

· Section 627.6131, Florida Statutes, which governs insurer payment and overpayment rules; and

· Section 641.3155, Florida Statutes, which governs HMO payment and overpayment rules.

Enforcement and Penalties

Failure to issue a timely refund in compliance with section 408.12 is expressly designated as an unclassified violation under section 408.813, Florida Statutes. The Agency for Health Care Administration (AHCA) may impose an administrative fine of up to $500 per violation, unless a different penalty is specified by law.

Individual Health Care Practitioners: New Section 456.0625, Florida Statutes

Parallel refund obligations apply to individual health care practitioners under newly enacted section 456.0625, Florida Statutes.

Under this provision, a practitioner who tenders charges for reimbursement, or any billing department, management company, or group practice that accepts payment for services rendered by the practitioner, must refund a patient overpayment within 30 days after the practitioner determines the overpayment occurred.

The statute adopts the same definition of “tenders charges for reimbursement” and includes the same exclusions for overpayments governed by sections 627.6131 and 641.3155.

Disciplinary Exposure

A practitioner’s failure to comply with section 456.0625 constitutes grounds for disciplinary action under section 456.072, Florida Statutes.

Expansion of Disciplinary Authority

The legislation also amends section 456.072(1) to expressly add failure to comply with section 456.0625, relating to patient overpayment refunds, as a specific basis for professional discipline by the applicable licensing board or the Florida Department of Health.

This amendment removes any ambiguity regarding enforcement authority and underscores the seriousness of noncompliance.

Practical Compliance Considerations

Health care facilities and providers should not treat this law as a mere billing technicality. It establishes clear timelines, creates affirmative refund obligations, and introduces meaningful enforcement risk.

At a minimum, providers should consider taking the following steps before the law becomes effective:

· Training billing and revenue cycle personnel to recognize when the statute applies

· Establishing internal procedures to identify when an overpayment has been “determined”

· Implementing written policies that mandate compliance with the 30-day refund requirement

· Ensuring that management companies and third-party billing vendors are contractually obligated to comply with the statute

With regulators increasingly focused on billing practices and patient financial protections, failure to operationalize these requirements may create unnecessary compliance and disciplinary exposure.

By: Carlos Arce

The landscape of the personal injury (PI) and personal injury protection (PIP) ecosystem has shifted dramatically in the wake of tort reform. Insurance carriers have adopted a more aggressive stance, intensifying audits, escalating clawback actions, and scrutinizing not only medical files but also the business arrangements behind the care. What was once a periodic review has, for many providers, become an existential threat.

Over the past year, this heightened scrutiny has led to significant market consequences. Smaller clinics have shuttered, mergers and acquisitions have accelerated, and many providers have exited the insurance and auto space altogether, opting instead for cash-based models. For those committed to remaining in the auto insurance sector, the message is clear: compliance is no longer optional, it is the foundation of the business model.

The New Carrier Playbook: Beyond the Chart, Into the Organization

Historically, disputes between providers and carriers revolved around clinical records, what was done, whether it was appropriate, and whether it was properly documented. Today, carriers are going beyond the clinical record to interrogate the entire operation. They are examining medical necessity and coding alignment, documentation sufficiency, treatment plans, ownership and control structures, licensure status, and the role of Management Service Organizations (MSOs). This expanded focus means that payment integrity investigations now include corporate and regulatory theories, which carriers often use as grounds to deny claims, demand refunds, or pursue broader repayment campaigns.

Common Allegations Driving Audits and Clawbacks

Providers are encountering recurring themes in carrier audits and clawback actions. One major area of focus is medical necessity challenges tied to coding. Carriers frequently allege that billed services are excessive, unsupported by the patient’s condition, or unjustified in frequency or duration. This often manifests as multiple visits per week with limited variation in findings, cookie-cutter documentation patterns, or high utilization of certain codes without individualized support.

Another common allegation involves billing without proper documentation or with documentation that doesn’t match the services billed. Carriers may point to missing contemporaneous notes, incomplete documentation, or internal contradictions, such as noting patient improvement while maintaining intensive treatment frequency. Routine

treatment plans and predetermined care pathways are also under scrutiny, with carriers treating repetitiveness as a proxy for lack of medical necessity.

Perhaps the most disruptive area of focus is improper ownership and control. Carriers are investigating whether facilities are operating outside required licensure, structured in a way that allows non-licensed parties to control clinical operations, or using MSO arrangements that cross the line into de facto ownership. In these cases, carriers argue that non-compliance with licensure or ownership regulations invalidates claims and justifies repayment demands.

Licensure Verification: A New Front in Compliance

Carriers are no longer relying solely on representations in credentialing or claim submissions. They are actively verifying whether providers are properly licensed and whether operational structures comply with regulatory requirements. This includes identifying technical defects, mismatches, or gaps in compliance documentation. In today’s heightened audit environment, these issues are treated not as administrative oversights but as triggers for clawbacks.

Market Impact: Closures, Consolidation, and the Cash Exodus

The aggressive posture of carriers has reshaped the PI/PIP market. Smaller operations without robust compliance infrastructure are closing, while mergers and acquisitions are increasing as providers seek scale and operational maturity. Many providers are leaving the insurance space altogether, opting for cash-based care where audits and repayment demands are less prevalent. The market is increasingly favoring clinics that can withstand scrutiny across clinical, billing, and corporate compliance domains.

Moving Forward: A Compliance-First Strategy

While new compliance efforts cannot erase past vulnerabilities, they can significantly reduce future risks. Providers committed to staying in the insurance and auto space must focus on three key pillars:

1. Licensure and Regulatory Compliance: Ensure the facility is properly licensed, renewals are up to date, and operations align with licensure requirements.

2. Policies, Protocols, and Documentation Standards: Strengthen documentation of medical necessity, align coding with care provided, reduce template cloning, and implement internal auditing processes.

3. Structure and Control: Verify that clinical entities are owned and controlled in a compliant manner, ensure MSO agreements reflect true management rather than

ownership, and address practical control points such as financial accounts, hiring authority, and profit flow mechanics.

The Bottom Line: Compliance Is Survival

The PI/PIP and auto insurance space is undergoing a tightening cycle. Carriers are more aggressive, sophisticated, and willing to leverage licensure and ownership theories to deny claims and demand repayments. For providers who want to remain in this space, the path forward is clear: adopt a deliberate compliance strategy that addresses licensure, documentation, coding, and business structures.

In the post–tort reform auto insurance ecosystem, compliance is no longer just about managing risk. It’s about ensuring survival.

By: Carlos Arce

On August 25th, the State Surgeon General issued a statement highlighting the risks associated with the use of dental amalgam in routine fillings, specifically mercury exposure. While this is not a prohibition, it is a clear signal from the state’s top medical authority that dentists should take additional care in how they approach these restorations.

For Florida dentists, this statement has two key implications:

1. Heightened Duty of Disclosure
Patients should be made aware of the potential risks tied to amalgam use. This means engaging in a clear, documented discussion about mercury exposure, alternatives, and the rationale for selecting a specific restorative material. The Surgeon General’s acknowledgment of these risks raises the expectation that providers address them directly.

2. Risk Management and Liability
The best tool to demonstrate that you have fulfilled this duty is a well-drafted informed consent form. While such documents will not shield you from malpractice or negligence claims, they provide critical evidence of disclosure and communication. A consent form should outline the risks of amalgam, note available alternatives, and confirm that the patient had an opportunity to ask questions.

Practical Guidance

• Review and, if necessary, update your existing consent forms to specifically reference amalgam risks.

• Incorporate the Surgeon General’s findings into patient conversations, both verbally and in writing.

• Train staff to reinforce these disclosures consistently across the practice.

Working with an informed consent document is not just a compliance step, it is the gold standard of risk management. It protects the provider by showing proactive disclosure, while also fostering openness and trust with patients.

By: Carlos Arce

As corporate practice of medicine (“CPOM”) restrictions continue to tighten across multiple states, stakeholders in the healthcare industry particularly those involved in multi-state operations must navigate a shifting legal landscape. These evolving regulatory frameworks increasingly limit the degree of control non-physicians may exert over medical practices. Yet, amid this national trend, Florida stands out as a jurisdiction that remains relatively business-friendly at least for the time being.

In Florida, medical practices that do not submit claims to insurance payors may be wholly owned by non-physicians. This unique flexibility removes the necessity for a Management Services Organization (“MSO”) as a structuring vehicle when payor reimbursement is not part of the revenue model. In such cases, a direct ownership approach can be used, sidestepping the typical Professional Corporation (“PC”) and MSO arrangement commonly seen in CPOM-restricted states.

However, when insurance reimbursement is part of the equation, the calculus changes. In these instances, non-physician ownership of a Florida practice must occur through a licensed Health Care Clinic (“HCC”), pursuant to Florida’s Health Care Clinic Act. This route provides a compliant pathway to receive third-party reimbursements while maintaining non-clinical ownership. Attempting to bypass the HCC model while collecting insurance payments can trigger regulatory scrutiny and jeopardize the practice’s legal standing.

For organizations with ambitions beyond Florida, a hybrid structure becomes a strategic necessity. One model I often recommend involves using the MSO as the licensee of the Health Care Clinic in Florida. This MSO entity can then serve as the foundational platform for expansion into CPOM-restricted states. In those jurisdictions, the MSO functions as a true administrative services provider offering back-office support, marketing, staffing, billing, and IT while clinical control is reserved to the PC and licensed physicians.

This structure offers several advantages:

               • Revenue Control in Florida: Through the HCC license, the MSO retains economic rights within the state.

               • Administrative Uniformity Across States: The MSO can standardize processes and compliance across multiple jurisdictions.

               • Scalability: The model allows for streamlined growth into states with CPOM restrictions without running afoul of local corporate practice laws.

Nevertheless, this structure is not without its complications. One of the key legal and operational challenges lies in aligning payor contracts across jurisdictions. Payor agreements entered into by a licensed Florida Health Care Clinic cannot simply be extended into CPOM states without careful legal structuring. Each state’s regulatory regime may require separate contracting entities, compliance protocols, and possibly, payor credentialing under distinct PCs.

Furthermore, the MSO model itself is under increased scrutiny. Several states have adopted or proposed “transaction review” statutes, requiring regulatory approval for certain management services agreements, equity transactions, or changes of control. Additionally, some jurisdictions are introducing or enforcing “entirety” rules that limit the scope of services an MSO can provide to a PC. These developments could curtail the flexibility of MSOs and demand more sophisticated structuring and documentation to withstand regulatory challenges.

As a result, MSO models are no longer plug-and-play. They must evolve to accommodate an increasingly fragmented legal environment, particularly for wellness enterprises, concierge medicine platforms, and retail health brands with national or multinational footprints.

Conclusion

While Florida remains a relatively permissive state for non-physician ownership of medical practices, particularly those not reliant on insurance reimbursements, that window may not remain open indefinitely. For ventures with multi-state aspirations, a forward-thinking, hybrid MSO structure offers the most strategic and compliant pathway balancing operational control in Florida with legally sound expansion into CPOM-restricted jurisdictions. Legal and compliance teams must stay vigilant, as the rules governing MSOs, clinic licensing, and payor relationships are in flux and under increasing state-level scrutiny.

Credit: Carlos Arce

The landscape of personal injury protection (PIP) is shifting, and one thing is clear: carriers hold a significant advantage. Through assertive settlement strategies, such as clawing back millions of dollars from providers or imposing severe non-billing periods, insurance companies are tightening their control. These actions are neither subtle nor temporary.

Insurance companies are doubling down. Their legal teams continue to expand, refining their expertise in audits, prosecutions, and pressuring providers. This evolving focus suggests that PIP audits and heightened regulations are more than just a passing phase. It’s a lasting trend, one aimed at reshaping the playing field in their favor.

But where does this leave chiropractic and other care providers?

For providers, the landscape may feel daunting—but it’s not insurmountable. It’s easy to feel frustrated and overwhelmed in this increasingly adversarial environment. The solution, however, lies not in accepting defeat but in being adequately prepared to meet the challenges head-on.

It’s critical to approach this era not with hopelessness but with strategy. Preparation and understanding can turn a difficult situation into one of opportunity. This involves: · Educating yourself about the audit and compliance processes.

· Building a proactive compliance framework within your practice.

· Developing legal strategies in collaboration with proficient attorneys and consultants who specialize in these cases.

Providers are not powerless. You have rights and the ability to push back. But success depends on knowing the rules, leveraging the tools available, and standing firm in the face of opposition.

Adaptation is key. The rules may have changed, but providers can thrive by equipping themselves with the knowledge to not just survive but to succeed. The dominance of carriers cannot be ignored, but it does not mean you have to surrender. With the right preparation, you can defend and protect what you’ve built.

The systems may seem stacked, but that’s not a reason to retreat. It’s a reason to rise.

By: Carlos Arce

If you’re a healthcare provider working under DCE (ACO Reach or ACO MSSP models), you’ve likely experienced the unique challenges of shared savings agreements. These programs can be a fantastic tool for improving care coordination and reducing costs, but as an attorney who has worked extensively in this field, I’ve seen firsthand how complex and frustrating these agreements can become.

One of the most common issues providers face is the denial of their shared savings payments, even when they believed they met the performance and contractual requirements. Unfortunately, these denials usually stem from two primary reasons:

· Contractual Performance Allegations: The ACO may claim that the provider failed to meet specific benchmarks outlined in the agreement, even in cases where the provider has upheld their end of the deal.

· Withholding Payments for Departing Providers: This often feels like a punitive measure. If you’ve decided to leave an ACO, you may find your payments withheld, with little transparency or explanation provided.

If either of these scenarios sounds all too familiar, you’re not alone.

What You Can Do to Protect Yourself

I often counsel providers in these situations, and here’s what I typically recommend to ensure you’re not left without the compensation you’ve earned:

· Understand Your Contract: Before signing any ACO agreement, ensure you and your legal counsel review the terms in detail. This includes payment timelines, performance benchmarks, and any clauses tied to program departure.

· Document Everything: Keep detailed records of your performance, patient outcomes, and compliance with all obligations under the ACO’s requirements. The more data you can provide, the stronger your case if a dispute arises.

· Communicate Regularly: Proactively communicate with your ACO throughout the performance year to confirm you are meeting their expectations. Regular check-ins can help address potential issues before they escalate.

· Seek Legal Support Early: If you suspect your payments may be at risk, consult an attorney experienced in ACO agreements as soon as possible. They can help you understand your rights and potentially negotiate on your behalf.

What frustrates me most about these disputes is how frequently they could be avoided with greater transparency and collaboration. Providers dedicate their work to improving patient outcomes and reducing costs, often at the expense of significant time and effort. When payments are withheld or denied, it’s not only discouraging but also deeply unjust.

If you’re experiencing challenges with ACO shared savings payments, know that you don’t have to face them alone. With the right approach and support, you can advocate for what you’ve rightfully earned.

Credit: Carlos Arce

In Florida, physicians (MD’s and DO’s) who supervise advanced practice registered nurses (APRNs) or physician assistants (PAs) must adhere to strict supervision regulations, especially when the supervision occurs outside of the physician’s primary practice location. According to Section 458.348(3)(c), Florida Statutes, specific rules apply when such supervision takes place at an additional medical office where the APRN or PA operates without the onsite presence of the supervising physician.

Key Provision Overview

This statutory provision allows a supervising physician to oversee an APRN or PA at one additional office separate from their primary practice, provided that the primary services offered at this additional location are dermatologic or skin care treatments. However, this supervisory arrangement comes with detailed regulatory conditions:

Mandatory Compliance Requirements

1. Board Notification

The physician must submit the addresses of all non-primary practice locations where they supervise APRNs or PAs to the Florida Board of Medicine. This ensures transparency and enables regulatory oversight. In addition, documentation of such supervision should be documented through a supervising physician agreement, often called a collaborating physician agreement.

2. Specialized Certification

The physician must be either: Board certified or Board eligible in dermatology or plastic surgery, as recognized under Section 458.3312, Florida Statutes. This ensures that the supervising physician has specialized training relevant to the dermatologic services being provided.

3. Geographic Limitations

The additional office must be: Within 25 miles of the physician’s primary practice location, or Located in a contiguous county (i.e., sharing a border with the county of the primary practice). Furthermore, the maximum distance between any of the offices may not exceed 75 miles, ensuring reasonable proximity for effective oversight.

Conclusion

Florida law sets clear boundaries for physicians supervising APRNs and PAs in satellite offices, particularly those focused on dermatologic services. By complying with the location, certification, and reporting requirements of Section 458.348(3)(c), Florida Statutes, physicians can ensure lawful and effective supervision while maintaining high standards of patient care. Physicians considering such supervisory arrangements should consult a health care attorney or the Florida Board of Medicine to ensure full compliance.