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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
FL
FLOIR-MRF-CPT-45378-MIA
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Florida Office of Insurance Regulation (OIR) & First Coast JN MRF Index — Miami-Dade MSA
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Miami-Dade County, FL
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Filing / IDR Window: 2026-11-24
[FLOIR-MRF-CPT-45378-MIA] Florida Blue & UnitedHealthcare GI Endoscopy / ASC MRF Rate Spread & FL Stat. § 627.6131 Prompt-Pay Audit (CPT 45378 / 43239)
Commercial payer MRF negotiated rate audit and Florida Statute § 627.6131 prompt-pay enforcement package for Gastroenterology & Endoscopy ASCs (CPT 45378 Diagnostic Colonoscopy, CPT 45380 Colonoscopy with Biopsy, CPT 45385 Colonoscopy with Lesion Removal by Snare, CPT 43239 Upper GI Endoscopy EGD with Biopsy, and CPT 00812 Monitored Anesthesia Care).
Cohort MRF 75th-Pct Value
$1,560,000
Target % of Medicare
12.65% MPFS
Statutory Authority
FL-GPCI-2026-MIA (Medicare Locality 09102-04 & FL Stat. § 627.6131 12% Prompt-Pay)
ERISA / Timely-Filing Window
380 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-45380 | Colonoscopy, Flexible; with Biopsy, Single or Multiple (ASC Facility + Professional) | CLAIM | 920 | $410.00 | $895.00 | $1,140.00 |
| CPT-45385 | Colonoscopy, Flexible; with Removal of Tumor(s), Polyp(s), or Lesion(s) by Snare Technique | CLAIM | 640 | $485.00 | $1,060.00 | $1,345.00 |
| CPT-43239 | Esophagogastroduodenoscopy (EGD), Flexible, Transoral; with Biopsy, Single or Multiple | CLAIM | 580 | $365.00 | $780.00 | $985.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
2047 Palm Beach Lakes Partners Llc (NPI 1992740674)1-4 Surgical Services, Llc (NPI 1215115373)Gastro Health South Florida ASC LLCBiscayne Endoscopy & Surgical CenterCoral Gables Digestive Health SpecialistsSunshine State Anesthesia Partners PA