Emergency Service Physicians are essential providers in the health care field. Generally, these valued practitioners render emergency treatment, management, and evaluation in the emergency room of our hospitals in Florida. Insurance Companies do not see our trusted emergency physicians in the same light. These PIP insurance carriers are continually underpaying and incorrectly reimbursing emergency service providers. Labovick Law Group strives to correct the injustices of the past. What injustices? Insurance companies’ failure to reimburse our emergency physicians who in most cases are performing lifesaving procedures or evaluations. Our goal as PIP litigators is to fight the insurance companies to ensure that emergency service providers are reimbursed correctly and to eliminate the industry-wide failure to reimburse correctly and timely. It is truly alarming that our emergency providers are unable to receive their just compensation despite providing such essential and lifesaving treatment and care.
To understand the intricacies of the emergency service provider portion of the PIP statute a quick historical background is necessary, followed by a brief explanation about the battle between reimbursement rates and PIP.
On January 1, 2008, the Florida Legislature enacted a revised PIP statute which created a mandatory reservation of $5,000 of the $10,000 PIP benefit, from which payment must be made for bills submitted within a specified timeframe by a “special class of providers.” Pursuant to Florida Statutes 627.736(4)(c), upon receiving notice of an accident that is potentially covered by personal injury protection benefits, the insurer must reserve $5,000 of PIP benefits for payment to physicians licensed under Chapter 458 or 459… who provide emergency services and care. The amount required to be held in reserve may be used only to pay claims from such physicians until 30 days after the date the insurer receives notice of the accident. §627.736(4)(c).
Explanation of Emergency Service Physicians and PIP
The above statute provisions were designed by the Florida Legislature to protect our emergency service providers. The Legislature adopted our core belief that emergency service providers are essential to the health care system. Florida personal injury protection law treats these physicians as a “special class” of providers. $5000 of the $10,000.00 of PIP in Florida is reserved to pay the claims of emergency service providers for 30 days. This ensures that emergency service providers are reimbursed for their important medical services and care. “Emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by another appropriate person under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility. See Florida Statutes 395.002(10).
The reasonableness of the charges is the main component of PIP litigation in Florida. Insurance Companies deny payment to medical providers alleging that their charges for medical treatment are too high. Providers can prove that their charges are reasonable by utilizing PIP litigation attorneys who hire expert witnesses and prepare Motions to assert the “reasonableness of the charges.” However, insurance carriers have been paying/reimbursing emergency service providers incorrectly on a historical basis without penalty.
The “new” PIP statute that was applied to Florida PIP claims as of July 1, 2012, allows insurers to limit payment according to a schedule of charges. See Fla. Stat. §627.736(5)(a)(5). Emergency service providers are entitled to, “the usual and customary charges in the community for emergency services and care… which are provided by medical doctors, osteopathic physicians, allopathic physicians, and dentists in hospitals.” Thus, MDs, DOs, APs, and dentists in the emergency department of hospitals are entitled to 80% of the usual and customary charges in the community for emergency services. Usual and customary refers to what the providers historically charge. The proper payment would be 80% of the usual and customary charges by emergency providers in the same geographic location (i.e. by zip code, by county).
The problem lies in the insurance companies treating emergency physicians as hospitals. Insurers argue that emergency providers are providing emergency services and care and this type of care is actually provided by a hospital. However, emergency providers are absolutely not “hospitals” and are generally separate entities contracting with hospitals to provide this important treatment and care.
Emergency providers are being reimbursed with the incorrect payment methodology, namely, 75% of their usual and customary charges. This imbalance has caused emergency service providers to lose out on hundreds of thousands, and possibly even millions of dollars throughout the years. Insurance companies pay and move on while our providers suffer. Although emergency physicians treat patients in the hospital, most physicians are independent contractors and are not employed by the hospitals. Thus, they should not be treated as if they were rendering treatment for emergency services and care provided by a hospital. The proper classification would be emergency services and care provided by medical doctors, osteopathic physicians, allopathic physicians, and dentists in hospitals, rather than “for or by” a hospital.
WHAT LABOVICK LAW GROUP OFFERS
LaBovick Law Group has experienced attorneys, legal staff members, and a business liaison who work to collect reimbursements for our providers on a daily basis. Emergency service providers are absolutely entitled to the disparity between what the insurance companies have paid them and what payments are mandated by them. We know that our emergency providers are integral physicians in the medical field and we strive to right the wrongs and injustices committed by insurance companies each and every day. We have the capability of performing a historical file review to capture exactly what patient files are ripe for a PIP suit due to the insurance company’s failure to pay 80% of the charges. We offer our file review/auditing process for free! We have specialized calculators and fee schedules to properly ascertain what reimbursement was proper for an individual policy.
If you or your company has been incorrectly paid 75% of their charges instead of the correct reimbursement equaling 80% of your charges, call LaBovick Law Group immediately to discuss what we can collect for you!