Medical Providers In Florida – What Should My Office Do If We Receive a Denial Letter From The Florida Personal Injury Protection Insurance Company?
Denial letters in Florida PIP claims are disheartening. You, the medical provider, render critical medical care to a motor vehicle accident patient. In turn, your office mails out a bill, but the Florida PIP insurance company denies the claim for a myriad of reasons. Your office doesn’t receive payment and the patient is set to follow up later that month. The honest truth is that it depends on the type of denial to determine what action, if any, is necessary. Do not simply give up and bill another payor. Contact the experienced Florida PIP attorneys at LaBovick Law Group to discuss the next steps. Below are common denials/defenses from Florida PIP insurers. A brief explanation will follow each of the 3 most common denials in Florida PIP claims.
What is a denial/partial denial letter?
A denial or partial denial letter is simply the Florida PIP insurer specifying why they:
1) Won’t pay a bill for medical service rendered.
2) Are underpaying a bill for medical treatment.
3) Are denying for certain codes and requesting additional information, etc.
Denial #1- No EMC Report
This is a common denial. Generally, in Florida, the PIP statute requires a medical doctor, osteopathic doctor, advanced registered nurse practitioner, etc. to determine whether a patient suffered from an emergency medical condition.
• The “EMC” portion of the statute was added in late 2012/early 2013. The goal of the EMC portion of the statute was to dissuade insurance fraud. The Legislature sought to limit PIP reimbursable accidents to those that caused serious injury. The legislature allows Medical doctors, osteopathic physicians, advanced registered nurse practitioners, dentists, etc. to render an emergency medical determination for purposes of Florida PIP. Unfortunately, the statute does not allow chiropractors to render an EMC determination.
The EMC portion of the statute has two-tiers of payment.
1) With an EMC determination: FULL policy benefits-$10,000.00
2) Without an EMC: Benefits are capped at $2,500.00
*This includes the situation where it doesn’t say whether or not the patient sustained an EMC in the accident.
If your office receives an EMC determination denial, indicating that limited or no PIP benefits will be reimbursed, follow these steps:
1. Check your office file to determine if your office qualifies to opine as to whether an EMC was sustained (MD, DO, ARNP, etc.). It’s important to note that an EMC determination can be made AT ANYTIME. There is no 14-day rule for EMCs.
2. Refer the patient out for an EMC determination if your office doesn’t have a medical professional that is permitted to render an EMC determination under the Florida PIP statute.
3. Once an EMC determination is made, send that out to the insurance carrier. If the EMC request was a (6)(B) request for information, wait 10 days and send the files to an experienced Florida PIP attorney if the PIP insurance company doesn’t send payment.
In summary, your office should get an EMC determination done as soon as possible. That will ensure benefits are paid to the maximum amount allowed under the policy ($10,000.00).
DENIAL #2 – Benefits Have Exhausted
This is probably the most common denial – claiming the Florida PIP policy benefits have been exhausted. Typically, Florida PIP policies contain $10,000.00 in PIP. Some contain Medpay.
1) It’s possible your office doesn’t know the amount of Medpay or about the existence of Medpay in that particular policy. This could mean that the insurer has underpaid this entire time and conveniently omitted the Medpay limits.
2) It’s very possible that the PIP insurer has paid for bills that were mailed in an untimely manner by other medical providers.
3) It’s also possible that the PIP insurer has paid for bills that shouldn’t have been paid, i.e. massage, acupuncture, etc.
In this case, it’s crucial that you don’t just move on immediately. Exhaust all resources. Send us your files. Let the experienced Florida PIP attorneys at LaBovick Law Group help you determine if benefits were exhausted properly. It’s quite possible the PIP insurer has issued a payment that doesn’t affect the PIP policy limits. After this analysis, move on to the next payor if it is determined that the Florida PIP insurer actually exhausted benefits in a proper way.
DENIAL #3 – Paid Correctly
This denial seems and sounds like a contradiction. How can a letter from the Florida PIP insurer indicating benefits were paid correctly, signal a denial?
It’s very possible that the Florida PIP insurer will pay for certain services rendered and deny others. This could be for several reasons, including the fact that Florida PIP insurers do not always agree with local Judges. A decision in Broward County yesterday may affect your patient accounts from as far back as 2015. The Florida PIP insurer may disagree with the local Judge and hedge their bets.
Also, the Florida PIP insurer may deny certain services you render. This is generally impermissible. For example, the Florida PIP Insurer may deny manual therapy because they believe it’s actually a massage. At that point, it’s crucial to contact the experienced PIP attorneys at LaBovick Law Group to discuss the next steps. We are always researching new decisions and creating precedent that affects the entire State of Florida. We can demand historical files to ensure you receive every penny due and owing. We can also litigate if necessary.
PIP is an ever-changing, dynamic statute. The statute changes as the law changes. PIP is a creature of contract and statute. Thus, a policy amended by one Florida insurer may create an underpayment for treatment rendered in years past. If it’s determined that benefits were actually paid correctly: it’s time to move on to the next payor. However, it’s always possible to go back and evaluate historical files. We could potentially get you a PIP reimbursement on a 2016 patient file you didn’t expect anything on.
LaBovick Law Group Can Help
LaBovick Law Group has been at the forefront of the Florida PIP battle since 1998. Our goal is to maximize your PIP benefits without any participation in terms of litigation. We know your time is valuable. We want to fight for you! Please give us a call today (561) 623-3681 to discuss how we can be your “Warriors for Justice.”