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What is a 627.736(6)(b) Request?

Far too often many of our my medical provider clients are confused when they receive a statutory 627.736(6)(b) request. As such, these documentation requests are often overlooked. If the request goes unanswered, the provider’s bills are not technically “overdue”.

Medical Providers and 627.736(6)(b) Request

A (6)(b) request can be found in Florida’s personal injury protection (“PIP”) statute. Fla. Stat. 627.736(6)(b) states in part, “every physician, hospital, clinic, or other medical institution providing, before or after bodily injury upon which a claim for personal injury protection insurance benefits is based, any productions, services, or accommodations in relation to that or any other injury, or in relation to a condition claimed to be connected with that or any other injury, shall, if requested by the insurer against whom the claim has been made, furnish a written report of the history, condition, treatment, dates, and costs of such treatment of the injured person and why the items identified by the insurer were reasonable in amount and medically necessary”.

Essentially, this part of the PIP statute gives insurers the ability to delay payment of a claim by requesting documents they feel provide a basis of how the treatment rendered was medically necessary. This statutory tool was designed to provide the insurer with a mechanism to investigate any frivolous claims prior to paying benefits for them. Nevertheless, it seems that insurers are using this tool to delay and deny claims instead.

In a typical PIP claim, the medical provider must submit their bill to the insurance company within 35 days from the date of service. Thereafter, the insurer has 30 days to make their investigation and pay the claim. If they do not pay after 30 days has lapsed, then the bill is overdue, and the provider can send a demand letter to the insurance company for the overdue bill. If, however, the insurer makes a written 627.736(6)(b) request in their response to the submitted bill, the 30 days to pay the claim is essentially “paused” until the provider produces the requested documents. Once a provider sends the insurance company the requested material, the PIP statute requires the insurer to pay the provider’s bill within 10 days after the insurer’s receipt of the requested documentation.

Ignoring A (6)(b) Request Does Not Make Your Problem Go Away

If the medical provider neglects to respond to this statutory request and initiates the demand process, it causes significant problems. Specifically, as stated above, the insurer’s obligation to pay within 30 days of notice of the bill is paused until their request is honored. If the request is never addressed, then the bill is not overdue and any demand letter or lawsuit on that claim would be premature.

It is important for medical providers to be aware of a (6)(b) request so they can ensure their bills are paid promptly. In most instances, these requests are found in the “explanation” section of the provider’s Explanation of Benefits. In other cases, the request can be made after the provider has sent the insurer a demand letter.

Whether you receive a (6)(b) request in an explanation of benefits or in response to your demand letter, providers should take the request seriously. As annoying as a request for additional documentation may be, providers are required to answer by law or else they will not be able to recover their benefits. The costs associated with sending in documents should not be a concern. This section of Florida’s PIP statute mandates that the person requesting such records shall pay all reasonable costs connected therewith. As such, anytime a provider sends documentation to the insurer in connection with a (6)(b) request, providers should also submit an invoice for any costs incurred.

Current State of (6)(b) Caselaw

The Case-

In a decision that came out on August 31, 2016, the Fourth District Court of Appeals set a precedent that will control the State of Florida when it comes to Emergency Medical Condition determinations and (6)(b) requests. The case of Medical Center of The Palm Beaches d/b/a Central Palm Beach Physicians & Urgent Care, Inc. a/a/o Carmen Santiago v. USAA Casualty Insurance Company (4th DCA, 2016) is the only DCA court to give an opinion on the issue of EMC, meaning that for the time this case is the controlling law in all of Florida.

The case states “The issue presented is whether a qualified medical provider must determine that an emergency medical condition exists for benefits to exceed $2,500 under Florida’s PIP statute. Stated in another way, if either there has been no determination of whether the insured has an emergency medical condition or there has been a determination that the insured does not have an emergency medical condition, would the benefits under PIP be limited to $2,500.” Further the case continues with “We find that the statute requires a determination of an emergency medical condition for the benefits to be up to $10,000. Further, we find that if either there is no determination of whether the insured has an emergency medical condition or there has been a determination that the insured does not have an emergency medical condition, then the benefits would be limited to $2,500.”

The facts of the case might sound very familiar to you and your medical office. They are:

“Carmen Santiago, the insured, was injured in a motor vehicle accident. She went to an urgent care center due to pain in her cervical region and right shoulder. The doctor referred her to appellant for physical therapy. Appellant then submitted bills for payment to appellee USAA, the insurer, but USAA provided no additional payment, explaining that, pursuant to section 627.736(1)(a)(4), Florida Statutes, $2,500 had already been reimbursed under the policy. USAA requested that appellant provide “the determination of the patient’s emergency medical condition by a provider authorized” so that USAA could make any additional reimbursement decisions.

Appellant sued USAA for breaching the insurance contract by failing to issue full payment for the medical treatment appellant provided. Subsequently, appellant sent USAA a note from Dr. Chang, the insured’s treating physician, which stated that he considered the insured to have an emergency medical condition. Upon receipt of this documentation, USAA paid all outstanding charges under the policy until the limits were reached. USAA moved for summary judgment, which the trial court granted, finding that the provisions of section 627.736(1)(a)(3)-(4) limit medical benefits to $2,500 until there is a determination that the insured had an emergency medical condition. The trial court also determined USAA properly requested that appellant provide information regarding the insured’s medical condition, pursuant to section 627.736(6)(b), to justify additional reimbursement. The trial court disagreed with appellant that USAA waived any defenses because it paid the medical reimbursement after the suit was filed, and determined there was no confession of judgment because USAA did not wrongfully withhold payment.”

The Need to Respond to EOR/EOB’s-

The important issue raised in this case is as it pertains to this article is whether a request for EMC determination will be treated like a 627.736(6)(b) request. Florida Statute 627.736(6)(b) states:

(6) Discovery of Facts About an Injured Person; Disputes.—

(b) Every physician, hospital, clinic, or other medical institution providing, before or after bodily injury upon which a claim for personal injury protection insurance benefits is based, any products, services, or accommodations in relation to that or any other injury, or in relation to a condition claimed to be connected with that or any other injury, shall, if requested by the insurer against whom the claim has been made, furnish a written report of the history, condition, treatment, dates, and costs of such treatment of the injured person and why the items identified by the insurer were reasonable in amount and medically necessary, together with a sworn statement that the treatment or services rendered were reasonable and necessary with respect to the bodily injury sustained and identifying which portion of the expenses for such treatment or services was incurred as a result of such bodily injury, and produce, and allow the inspection and copying of, his or her or its records regarding such history, condition, treatment, dates, and costs of treatment if this does not limit the introduction of evidence at trial. Such sworn statement must read as follows: “Under penalty of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief.” A cause of action for violation of the physician-patient privilege or invasion of the right of privacy may not be brought against any physician, hospital, clinic, or other medical institution complying with this section. The person requesting such records and such sworn statement shall pay all reasonable costs connected therewith. If an insurer makes a written request for documentation or information under this paragraph within 30 days after having received notice of the amount of a covered loss under paragraph (4)(a), the amount or the partial amount that is the subject of the insurer’s inquiry is overdue if the insurer does not pay in accordance with paragraph (4)(b) or within 10 days after the insurer’s receipt of the requested documentation or information, whichever occurs later. As used in this paragraph, the term “receipt” includes, but is not limited to, inspection and copying pursuant to this paragraph. An insurer that requests documentation or information pertaining to reasonableness of charges or medical necessity under this paragraph without a reasonable basis for such requests as a general business practice is engaging in an unfair trade practice under the insurance code.

The court in this matter keyed in on the wording condition to qualify that requesting an EMC determination was in essence a request for the condition of the patient as prescribed in 6b. “Based on the plain language of this subsection, as well as the title of the subsection, it is clear that the focus of this provision is the discovery of documents regarding the treatment and related billing of the individual injured person.” State Farm v. Delray Med. Ctr., 178 So. 3d 511, 515 (Fla. 4th DCA 2015). In the instant case, USAA appropriately requested a report on the insured’s medical condition. The report could likely have impacted USAA’s evaluation of whether a qualified medical provider had determined that the insured’s injury constituted an emergency medical condition. Consequently, appellant’s demand letter was premature. Although appellant filed a demand letter for payment of benefits, appellant failed to respond to USAA’s request for discovery pursuant to section 627.736(6)(b).”

What Does This All Mean?

The determination in the above raises issues for medical providers.

This case establishes that if you receive an Explanation of Benefits or Explanation of Review that states that they are looking for the condition of the patient or an EMC status that this acts as a 6b request. Meaning, you must respond to this request with the EMC determination or the condition of the patient. Failure to respond will do two things. 1) Your bill will not be deemed “overdue”. 2) Sibley Dolman Gipe Accident Injury Lawyers, PA cannot send a demand letter for you.

I remind you from other blog posts that only “overdue” claims can be demanded under the Demand Statute (627.736(10). If you fail to respond to the request and send the dates of service to my firm for demand I will not be able to demand those dates of service until after you submit the EMC determination and then wait 10 days from the receipt of such for the insurance company to make a determination. Meaning, you need to wait 10 days, after receipt and then another 5 (for mailing), for a total 15 days before giving us the dates to demand for payment.

What to Do When You Have Sent the Insurance Company Everything You Have on the Patient

As listed above in the statute not everything titled a (6)(b) request will be deemed by the courts to be such. They can’t just ask for random things and get them. It must fit into the wording or meaning of the statute. The courts have ruled that some requests do not qualify under (6)(b). So what do you do if you have sent what you have? Sibley Dolman Gipe Accident Injury Lawyers, PA recommends to not ignore the letter. Instead to draft a response to the insurance company that says.

“In regards to the alleged Fla. Stat. 627.736(6)(b) request, my office has tendered you with all the documentation we have. At this time please consider this our full response to your alleged request and proceed to determining reimbursement. Failure to respond within 10 days of receipt of this response will leave all bills overdue and we will proceed with sending a demand letter pursuant to Florida Statute 627.736(10). This response is not an admission that you have sent a valid Fla. Stat. 627.736(6)(b) request”

So what will that letter do for your office? First it does not admit that their request was valid. What it is doing it hitting the ball back over to their side. Giving them the 10 days to make a determination. Either they will pay or not pay. At this point however, after the 10 days from receipt of your letter and a few days for mailing (give them 15 days) your bill is now overdue, any way you cut it. Now you can proceed with sending the file to the attorney to handle from there on out.

Contact Florida PIP Litigation Firm Sibley Dolman Gipe Accident Injury Lawyers, PA

At the Sibley Dolman Gipe Accident Injury Lawyers, PA, we have an entire department dedicated to serving medical providers who have had their PIP bills denied. Our Florida PIP claim attorneys are well versed in Florida’s no-fault law and aggressively handle PIP claims on behalf of their providers. If you are a medical provider and have had your PIP benefits denied, contact the Sibley Dolman Gipe Accident Injury Lawyers, PA at 727-222-6922.