State Farm, GEICO, and many other PIP insurance carriers are improperly reducing your bills for medically necessary services/care you provide. Your medical practice may have claims in need of review due to these incorrect reimbursements. Insurance carriers are coding your medical bills with strange Medicare reductions without notifying the insured and/or your office about the potential for utilizing these methodologies. These insurers are tasked with including Medicare coding information in their PIP automobile insurance policies. Call our office for a review of your files, the various policies, and everything PIP to ensure you are being properly reimbursed.
What the insurers are attempting to do, coding, and what you can do to defeat the insurance carrier!
What is Coding?
As you may know, the Florida PIP law was amended in 2012. Insurance companies were given permission by the Legislature to pay your bills based on the Medicare Fee Schedule and its accompanying payment methodologies. Your medical bills may be coded with strange terms such as NCCI (National Correct Coding Initiative), Multiple Procedure Payment Reduction (“MPPR”), and Physician Assistant 85% reduction codes. If your bill is coded with one of the above codes or something else entirely, you may be missing out on additional dollars!
What’s the problem with this Coding?
Most PIP insurance carriers are utilizing the above coding without providing notice of such in their policies. Using State Farm as an example: Your office bills 97140 for manual therapy. State Farm indicates on their Explanation of Benefits that 97140 is being reduced relying on Medicare’s Multiple Procedure Payment Reduction rule. However, in this scenario, the MPPR was not specifically mentioned in State Farm’s PIP policy. The result? The insured and your medical office were not given notice that certain bills would be subject to an MPPR reduction. Florida PIP case law requires an insurance company’s policy to clearly elect the MPPR. This election must be both clear and unambiguous to put all involved parties on notice!
PA’S And Nurse Practitioners
Physicians’ Assistants and Nurse Practitioners are a vital part of any clinic. These medical professionals render medically necessary services to patients. Medicare coding allows for payment to PAs and nurse practitioners at 85% of the Medicare fee schedule. That is a 15% reduction which may or may not be permissible.
Permissible if-insurer includes this payment methodology in their policy. A simple declaration indicating the insurer will pay pursuant to the Medicare coding methodologies including the PA/Nurse services reduction is most likely allowable.
Impermissible if The insurer surprises your office with an improper payment. The notice must be given in the form of a clear recitation of what is permissible under the policy. Without said notice the insurer is subject to a PIP suit and full reimbursement is required!
Insurers will continue this coding!
Insurers will continue to incorrectly and improperly reimburse providers if providers give up the fight and simply decline to pursue PIP suits. It is your legal right to ask for what is yours. Insurance companies are taking advantage of medical providers who prefer to remain off the litigation radar. The irony of the situation is, insurers usually pay correctly once your office hires an attorney to serve a PIP Suit. Nine times out of ten the insurer will correct their wrongs in subsequent bills/claims they receive from your clinic.
What your clinic should do:
Pip Insurers will continue to improperly pay until a majority of medical providers take a stand and fight ambiguous policies and incorrect payments. Insurers have a duty to be transparent. That is, insurers are tasked with clearly electing to pay a certain way in their policies. If an insurer wishes to utilize the Medicare fee schedule, the policy must reflect a clear choice to use the fee schedule. However, simply electing to pay based on the Medicare Fee Schedule is not enough within itself to justify using one of the above Medicare payment methodologies. The insurer has to go the extra step by including language within their policy about MPPR, NCCI, 85% reductions, and the like. Send us your bills! Send us your EOBs! We will do the rest. We litigate all of these unique issues on a daily basis. We have the proper arsenal to counteract the insurers’ shady business practices.
IF YOU ENJOY READING CASES DESCRIBING THE ABOVE INFORMATION, PLEASE SEE BELOW!
A recent case in Miami Dade County ruled that an insurer MUST clearly elect to pay pursuant to Medicare Coding Methodologies in the company’s policy. Specifically, State Farm failed to mention anything regarding MPPR reimbursements in its policy. The Miami-Dade Court held that State Farm could pay per the Medicare Fee Schedule, but COULD NOT utilize the MPPR. Please see Pan Am Diagnostic Services, Inc. a/a/o Cristina Lasaga v. State Farm Mutual Automobile Insurance Company, 22 Fla. L. Weekly Supp. 1165a (11th Jud. Cir. Miami-Dade County, April 30, 2015).
(Includes Summary of the Case).
Insurance — Personal injury protection — Coverage — Medical expenses — PIP policy that states the insurer will pay 80% of allowable amount under participating physician fee schedule of Medicare Part B clearly and unambiguously elects to limit reimbursement to permissive statutory fee schedule — Policy’s general references to coding policies and procedures does not clearly elect use of multiple procedure payment reduction rule that insurer used to reduce payment below permissive statutory fee schedule.
Please feel free to contact me directly at 561-625-8314, to discuss anything PIP-related! I am happy to answer any questions or concerns. We pride ourselves in keeping up to the minute updates regarding our vastly complex Personal Injury Protection law. We have a large PIP team that handles all PIP-related matters from the Demand Process to the Litigation stage of the claim.
We have a business development manager/client liaison, Liliana Davidson, who would be happy to discuss any PIP-related matter with you. You can contact her at (561) 623-3681.