Some doctors are fighting back against the PIP carriers. Others are concerned they would be blackballed or red-marked by the insurance companies.
Do not be afraid to FIGHT BACK! Insurance Companies do not deal in fairness or truth. They deal in money and intimidation. The EMC Peer Review Reports are a scare tactic designed to decrease the volume of claims carriers have to pay. It is amazing this works at all; but, it must because carriers would not do them if it were not profitable.
Document everything! Make sure a medical provider clearly notes in the patient’s file that they suffered an EMC. If the patient needs to see an MD, DO, PA, etc. refer the patient to one of those providers. If you need help please call us.
If you receive an EMC Peer Review Cut-off, call our office immediately! The consultation is FREE. We will not charge you to get your benefits started! We will come to your office at no charge to evaluate your file(s).
WHY YOU SHOULD FIGHT:
You are a medical professional. You are credible and honest. Your profession revolves around the well-being of your patients. You are licensed to do business in Florida and you are entitled to fair pay and benefits. Why allow a PIP Insurance Company to dictate what an EMC is and what it is not? That is for you and your patient’s other doctors to determine.
Florida law protects you if any doctor finds an EMC at any time. The EMC report doesn’t require special language. The EMC statute DOES NOT specify what must be included in your medical records and SOAP notes. Recently, a Judge in Orlando ruled a patient who required surgery met the criteria for an EMC despite the medical provider’s failure to include an EMC determination in his notes.
TO WIN: IMMEDIATELY obtain an EMC from one of the statutorily permitted providers listed below:
- Medical Doctors (MD)
- Osteopathic Physicians (DO)
- Physician Assistants (PA)
- Advanced Registered Nurse Practitioners (ARNP)
- Dentists (DDS or equivalent)
Call us if the carrier declines payment, we will fight for you!
WHY ARE THE PIP CARRIERS DOING THIS?
Progressive started this system to discourage medical providers from filing PIP suits in EMC cases. Progressive is trying to cap PIP reimbursements at $2,500. If even a small percentage of providers give up on their right to $7,500. The company is sitting pretty! Also, it forces the patient to worry about seeing their doctor and stop going for fear of a large outstanding medical bill. That is UNFAIR and should not happen.
GOOD NEWS – CASE LAW BACKS PROVIDERS
On July 30, 2015 in Hess Spinal & Medical Centers, P.A., a/a/o Ton’Taja Butler, 23 Fla. L. Weekly Supp. 177a (July 30, 2015, 13th Jud. Cir.), the Court stated the FLORIDA PIP STATUTE DOES NOT PERMIT THE INSURER TO CHALLENGE AN EMC DETERMINATION BY A TREATING PHYSICIAN.
Most jurisdictions agree that the PIP Insurance Company CANNOT use a doctor to get an EMC Peer Review. Florida Statutes Section 627.736(1)(a)(1)-(1)(a)(4), only requires a qualified medical provider (see above list) to indicate whether a patient suffered from an EMC.
The Insurer IS NOT PERMITTED to: (A) Challenge an EMC determination, (B) Take your Deposition in an EMC Cut-off Case, and (C) Cap policy benefits to $2,500 if you or another treating physician has stated the patient suffered from an emergency medical condition.
State Farm is currently sending documents requesting an Emergency Medical Condition determination if they cannot locate one within the initial documents your office sends. Unlike Progressive, State Farm (at this time) has not been capping your benefits at $2,500 if you are unable to render an EMC determination.
IS A FORMAL EMC REPORT NECESSARY?
A formal report IS NOT required. You need only write a few words in your notes to document an EMC.
NO magical words are required!
Insurers CANNOT penalize you for failing to use a special form or particular language.
BEST PRACTICE IS TO SPELL IT OUT: Put your EMC determination in the INITIAL EVALUATION. Indicate the patient suffered an EMC in the analysis/determination portion of your daily/medical note.
As an example: The law already determined the following are EMC conditions:
- A patient who required surgery of his clavicle
- Radicular symptoms (all radicular symptoms rise to an EMC)
- Disc Herniations (any level or HNP is an EMC)
- Disc Bulges (see number 3 above)
- Broken Bone in a patient’s wrist (any broken bone is an EMC)
- Extreme pain causing a patient to miss work (any subjective pain of significance can be an EMC)
AN EXAMPLE OF EMERGENCY MEDICAL CONDITION LANGUAGE WE RECOMMEND (The definition of EMC is the second sentence, it is NOT required, but you are welcome to use it as it really clarifies you know what an EMC entails!):
Upon examination (List patient’s injuries/objective findings), it is my medical opinion (Patient’s Name) __________________ has suffered from an emergency medical condition. An emergency medical condition is defined pursuant to Florida Statutes 627.736 as a “medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to patient health, and/or serious impairment to bodily functions, and/or serious dysfunction of any bodily organ or part.”
MAXIMIZE YOUR EARNINGS:
LaBovick Law Group is well-versed in the most up-to-date changes in the law. We have successfully litigated hundreds of EMC cases. We have become so versed in this area of the PIP Statute that not one of our providers has ever needed to sit for a deposition in an EMC case! We are able to conduct a 5-year historical review of your MVA files and demand using our proprietary PIP Claim Software in light speed. Our firm does not discriminate between easy and complex cases. We provide our clients monthly status reports. Most importantly, our business is to maximize your earnings in the least amount of time!