Scenario 1 – MRI Facilities cannot be Reimbursed without HelpPatient presents to an MRI facility after a few weeks of medical treatment on referral from their treating physician following a motor vehicle accident. The MRI facility fulfills the script, submits their charges on a HCFA (CMS 1500) to the patient's PIP insurer, and then receives an EOB/EOR denying the claim because the insurer is awaiting documentation of an emergency medical condition. What is the MRI facility supposed to do? It is in the business of performing scans from referring physicians, and not involved in the actual treatment of injured persons. The MRI facility finds itself in a situation where its payment is now DEPENDENT on the actions of third party medical providers AND the insurance company's acceptance of any EMC opinions those third party providers may write. MRI facilities are placed in a grossly disadvantaged position because they cannot author EMC opinions, they cannot submit anything other than an MRI report, and their charges hang in limbo…indefinitely! Did the Florida legislature intend this unintended consequence of leaving select medical providers in limbo, pending an ambiguous NON-MEDICAL, legislature and insurance created term? What if the patient's other providers submit medical documentation but never use the magic words “emergency medical condition”? Other medical providers, such as medical doctors and physiatrists, who are administering active treatment to their patient are in a position to amend and/or supplement their office notes with those magic words and have their bills paid and the EMC condition met. MRI facilities are not in such a position, and are therefore placed in an unequal bargaining power relationship. The insurance companies have successfully corralled MRI facilities and placed them in an impossible predicament leaving them with their only recourse – litigation!
Scenario 2 – Chiropractors are not Authorized to Make an EMC DeterminationThe patient described in Scenario 1 was referred by a chiropractor. Per Fla. Stat. 627.736(1)(a)3, a chiropractor is noticeably excluded from making a determination a patient has an emergency medical condition and therefore payment of his bills beyond $2,500.00 rests in an EMC determination being made by the specified providers in sub-subparagraph 3. Just like MRI facilities, chiropractors are placed in an unequal bargaining relationship relative to other providers and their medical determinations. The insurance companies can send all the 6(b) requests they want to a chiropractor requesting documentation that their insured/patient sustained an emergency medical condition, but it is a request that the chiropractor and/or MRI facility is unable to comply. For one, the legislature blatantly excluded chiropractors from making an EMC determination. The unintended consequence is that chiropractors are placed in a predicament of referring the patient to another physician and hoping that physician will give the insurance company what they want: the magic “emergency medical condition” words, which is not a medical term in any way. Is that the game patients and providers now have to play?
The Florida PIP Statute may be UnconstitutionalThe disturbing trend in both of these scenarios is the unfair bargaining power and the seemingly impossible predicament that MRI facilities and chiropractors are corralled in. At Dolman Law Group Accident Injury Lawyers, PA we actively seek all EMC cases where benefits have been unfairly capped at $2,500.00 due to emergency medical condition, which is an arbitrary standard at best. If you are a medical provider, anywhere in the State of Florida, and your PIP benefits have been limited to $2,500.00 due to the emergency medical condition provisions in the No-Fault statute, we are willing and eager to help. We have represented dozens of providers in countless claims involving EMC. Please call us if you have any questions or concerns on navigating the EMC provision and how we can help. Dolman Law Group Accident Injury Lawyers, PA is proud to represent medical providers and independent MRI facilities across Tampa Bay, including but not limited to the counties of Pinellas, Hillsborough, Pasco, Manatee, Sarasota, Hernando, Citrus, Polk, and Charlotte. We are able to represent any provider across the State. Contact Stephen Farkas at 727-451-6900 for a free evaluation. Dolman Law Group Accident Injury Lawyers, PA 800 North Belcher Road Clearwater, FL 33765