A plethora of medical providers are being short-changed by their patients’ personal injury protection (PIP) insurers. Some of these insurance companies are underpaying, mispaying, or even refusing to make payment altogether. Generally speaking, the insurer is refusing payment for all of the wrong reasons. It is essential to have a PIP litigator in place to fight the good fight and to ensure that all valid payments are in fact made by the insurance carrier.
Common reasons for underpaying or paying the incorrect benefit amount:
- Many times, the insurance company will misapply the deductible. Instead of applying the deductible to the total bill, as they should, the insurance company will apply the deductible to the amount that they reduce the bill by. In layman’s terms, the insurance company will reduce the bill by 80% of the reasonable amount and then apply the deductible. In the correct method of application, the insurance carrier will apply the deductible after the total amount billed, prior to the reduction.
- Insurance carriers must correctly apply the updated 2013 PIP amended Medicare coding policies. The insurer cannot reduce bills based on the National Correct Coding Initiative’s Medicare Reduction Policies, Hospital Outpatient Payment System, etc. If they do, these are incorrect reductions. For example, in Socc v. State Farm, the 5th DCA held that the Florida Statutes do not support a finding that the Legislature intended to incorporate all of Medicare into the PIP statute.
- “The insurer believes that they paid a reasonable amount.”As an incorrect method, the insurer will defend as per Florida Statutes 627.736(5)(a)(2) indicating that they have included a permissive fee schedule into their policy when in reality they have yet to amend their policies. Keep in mind that the insurer must give notice to the insured before using Medicare fee schedules to limit reimbursements for medical services. This specific notice must be found in the insurance policy, specifying that the insurer is taking advantage of the Medicare fee schedule, Workers Compensation Fee Schedules, etc.
- The insured fails to attend an examination under oath (EUO). A missed EUO does not and should not result in non-payment to the medical provider. It is not a condition precedent, meaning an event that must take place prior to obtaining PIP benefits.
- Assignment of benefits is a mere direction to pay and is invalid. An assignment of benefits is valid, even if it appears in the form of a direction to pay. There is no legal distinction between an assignment and a direction to pay.
The above “excuses” are a few of the multitude of defenses raised by Florida PIP insurance carriers. It is essential to contact an experienced PIP litigator to ensure that the insurance company does not incorrectly payor omit to pay a medical provider for the medical services rendered. Insurers frequently apply the incorrect payment methodology and incorrectly apply current case law. Do not give up fighting the good fight! Contact an experienced PIP lawyer to fight that fight and get you what you are entitled to.