As , we understand the nuances and intricacies of Florida's no-fault law and the . We constantly inform our clients, medical providers, and colleagues about the different areas of PIP law that apply to them. I believe that medical providers, including billing managers, are the ones who must have a basic understanding of PIP because they are the ones receiving repayment for their services.In our practice, we receive questions from the same subject areas: PIP coverage, physical and manual therapy, and what constitutes an emergency medical condition (EMC). Therefore, a helpful refresher may benefit everyone. If you require the services of a PIP attorney either to help you with the process of applying for benefits or to help you get benefits from an insurance company denying your claim, contact the PIP attorneys at Dolman Law Group.
Florida PIP Insurance ExplainedPIP stands for personal injury protection, a type of no-fault health insurance that covers medical expenses, lost wages, and other economic damages in the event of a Florida accident. Florida is a no-fault state requiring its drivers to purchase personal injury protection to allow them to recover compensation for damages caused by a car accident. Following a car accident, victims will have to pay for steep expenses, which personal injury protection serves to help with. PIP insurance pays up to $10,000 worth of applicable damages after an auto accident. The following are some of the expenses PIP covers:
- Medical costs
- 60% of lost income
- Funeral expenses
- Ambulatory services
- Hospital expenses
- Surgical and rehabilitation costs
How Does Personal Injury Protection Insurance Work?There are nuances and intricacies for who and how a car accident victim can receive PIP benefits. Both victims and insurers need to know these details as outlined in the Florida PIP statute 627.736. The severity of car accident injuries, how long it takes them to get medical treatment, and whether they were in a car can alter whether someone can receive PIP benefits. The following are some of the details that can affect whether someone can receive PIP benefits:
Did the Car Accident Victim Receive Medical Attention Within 14 Days?
A recent amendment to the Florida PIP statute made it so car accident victims had to receive medical treatment from a healthcare professional within 14 days of the motor vehicle accident. The idea behind this rule is that if the injury is severe, the victim will go to the hospital to receive treatment.This prevents those without a severe injury from receiving benefits they do not need. If the car accident victim does not receive medical treatment within 14 days of the accident, they will not have access to PIP coverage benefits.
Healthcare providers should ensure their intake forms and patient consultation covers whether or not the patient followed up with a primary care physician, hospital, walk-in clinic, or received roadside emergency service. Even if your patient did not go to the hospital via EMS, initial services and care provided by a person or entity who provides emergency transportation and treatment qualify as establishing treatment within 14 days. See Florida Statute .
Does the Car Accident Victim Own a Car?
If the patient did receive treatment within 14 days, then the PIP lawyer will want to know whether or not the patient owned a car. PIP coverage applies if they own a car, and the victim must make the claim with your patient's PIP insurance carrier. Motor vehicle owners can receive PIP benefits, as they are required to purchase PIP insurance to cover their vehicles. However, if a car accident victim does not own a car, receiving PIP benefits could be challenging.
You can be the victim of a car accident and require compensation for damages as a passenger during a car accident. Without your own PIP insurance, you could receive coverage from a relative that you live with who has PIP coverage. You can make a claim with their insurance provider and recover compensation for damages. If you were the passenger in a vehicle involved in a car crash, you could make a claim on the driver's PIP insurance to receive benefits for car accident injuries.
Are Pedestrians and Bicyclists Covered Under PIP?
Pedestrian and bicycle accidents can result from a driver's negligence that breaches a duty of care. Whether they can receive compensation for damages caused by a car striking them depends on whether they own a car.As outlined above, they can receive coverage if they own a car and have purchased PIP insurance. If not, they can make a claim on their relative's PIP insurance. If neither of these circumstances applies to pedestrians or bicyclists, they can file a claim with the at-fault party's insurance company.
Not all patients will have an attorney or want representation, so providers must ensure their intake forms are complete and thorough in establishing insurance coverage. A provider can establish insurance coverage by asking questions about whether the pedestrian or cyclist owns a car or if they live with a relative that owns a car.
Who Can Render Medical Services Under Florida PIP Law?
Medical doctors, doctors of osteopathic medicine, hospitals, and EMS services can all render medical services under Florida PIP law. The amended Florida PIP statute does not allow massage therapists or acupuncturists to bill PIP for medical services rendered. Furthermore, massage therapy and acupuncture services are no longer covered even when a medical doctor is overseeing such services.Under Florida PIP law, PIP insurance covers initial care and services provided by a M.D., D.O., D.C., dentist, hospital, facility owned by a hospital, and emergency medical personnel within 14 days after the car accident. The initial care and services may also be supervised, ordered, or prescribed by those mentioned above.
What is an Emergency Medical Condition (EMC)?
According to , an emergency medical condition (EMC) is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate attention would be reasonably expected to result in any of the following:
- Serious jeopardy to the patient's health
- Serious impairment to bodily function
- Serious dysfunction of any bodily organ or part
When Should a Healthcare Professional Determine Whether the Victim Has an EMC?
Although the law does not specify, the medical provider should determine an EMC after the MRIs and related diagnostics, so they can adequately support the EMC conclusion with clinical correlation. It is wise to correlate all clinical findings and presentations with diagnostic results at the earliest opportunity.In disc injury cases with discogenic symptomatology, it may be wise to involve an interventional pain physician (anesthesiologist or physiatrist) sooner than later. If the client's pain and clinical presentation do not improve over a finite period of time (three months) and injections fail to alleviate the symptoms, it will be much easier for the interventional pain doctor to substantiate a finding that the victim has met the EMC threshold.
A patient that has failed conservative care and injection therapy should be evaluated by a surgeon, as evidenced by their inability to improve after all less restrictive measures aside from surgery. This bolsters any argument that the claimant has sustained an EMC, even if the physician did not expressly state the words "emergency medical condition."
Does an EMC Have to be Established Within 14 Days of the Accident?To receive PIP benefits, you need two things: to receive medical treatment within 14 days and have a doctor determine that you suffered an EMC. There is a growing misconception that an EMC determination must be done within 14 days to establish PIP coverage, which is not true. The 14-day rule opens PIP to at least $2,500 in coverage. The law does not say when an EMC has to be provided. Although your doctor will most likely be able to determine that you suffered an EMC after your first trip for medical treatment, you may have an injury with delayed symptoms. The severity of the injury may not become clear until after the 14 days required to seek medical attention. If your car accident injury escalates to an EMC, you should visit your healthcare provider again, so they can make a record of your condition to receive PIP benefits.
How Does the EMC Cutoff Work?
This is a black and white area with some shades of gray. Simply put, PIP in Florida is limited to $2,500 if treatment occurs within 14 days but no "emergency medical condition" exists. Note, however, that such a determination does NOT have to be made within 14 days.Likewise, PIP is limited to $10,000 if treatment occurs within 14 days and the patient is diagnosed with an "emergency medical condition." Again, the EMC does NOT have to be made within 14 days. The gray area comes into play when the patient receives treatment within 14 days, but:
- No provider says anything one way or the other regarding an EMC
- What form the EMC needs to be
- If a peer review can effectively limit PIP to $2,500
- When the EMC should be done
- If hospital treatment counts as establishing an EMC
What Form Should the EMC Take?
Ideally, your healthcare professional should note the EMC as more than just a checked box to avert the insurance company's suspicion. An EMC should be incorporated into an initial office note where a comprehensive examination is done, complete with the patient consultation and MRIs, or a subsequent follow-up visit if MRIs were not previously done.While not required, it is highly recommended to use the language of the statutory definition to alleviate any ambiguity or lingering questions by the insurance adjuster. In other words, be sure to word your statement about the EMC with similar language to that found in the statute.
Should Billing Continue if the PIP Benefits Are Lowered to $2,500?Car accident victims should always continue billing, whether the PIP benefits are capped at $2,500 or $10,000. This also applies if PIP benefits are suspended due to an Independent Medical Examination (IME) or peer review. In the event the EMC is overturned, bills will be paid in the order received.
Does PIP Pay for Manual or Massage Therapy?Whether your PIP insurance covers manual or massage therapy depends on the insurance carrier. As with all insurance plans, PIP coverage depends on what is agreed upon by the insurance company and the signee.
For example, Progressive and USAA routinely deny CPT 97140 (manual therapy) charges on massage therapy grounds, while other carriers pay without much hesitation. Dolman Law Group has successfully received payments for clients from providers during pre-suit demand in cases of manual therapy (CPT 97140) denials.
Ambiguities in Florida PIP Insurance
The PIP statute, as written, fails to state whether an insurance claims adjuster maintains any responsibility or duty in determining whether an EMC exists in the absence of a qualified physician using the words "emergency medical condition."For instance, will the insurance adjuster deem the condition to be an EMC if a car accident victim sustains a very serious spinal injury, warranting the need for immediate surgical intervention? Is it an EMC even if the treating physician or surgeon failed to expressly state "emergency medical condition" in their notes or diagnosis? From the above example, it is clear that the hypothetical car accident victim has suffered an injury that meets the requirement of their injury, causing serious impairment to bodily function or dysfunction of a body part. This is readily apparent by the immediate need for surgery. Do Florida PIP laws require the handling claims adjuster to make a reasonable interpretation of whether an EMC exists based on the available medical records? Not all physicians receive training in diagnosing or utilizing the term EMC in medical school or residency. The Florida legislature created this term during an obvious victory for the insurance industry.
PIP Lawsuits Jury Verdicts
Another ambiguity is whether the setoff for bodily injury jury verdicts remains at $10,000 or is it now $2,500 in cases where no determination of an EMC exists? Currently, the defendant is entitled to an offset of $10,000 for any judgment where a collateral offset exists (i.e., insurance benefits such as no-fault coverage).Based on the amended Florida PIP law, one can argue that the insurance carrier is no longer entitled to an offset in the amount of $10,000 when the benefits are limited to $2,500 based on a determination or lack thereof of an EMC. Although the insurance carrier will argue that the policy in effect is for $10,000 in PIP benefits, this is akin to a sale of false goods.
In an analysis of the amended Florida PIP laws, one should focus on the benefits that are available as opposed to the benefits contracted for when determining the offset. The amended Florida PIP statute clearly states that the car accident victim receives $2,5000 in benefits when no EMC is determined.When a physician determines that there is an EMC, $10,000 in benefits is available. What happens when a physician fails to determine whether the injury meets the threshold of an EMC? Florida statute and case law are currently silent on what shall occur when no determination of the existence of an EMC is made.
The Florida PIP Statutes Offer Little Room for Error for Medical Practitioners
As it presently stands, the statute leaves several issues unanswered with little guidance for Florida medical practitioners. Again, we are left to inquire what duty the claims adjuster has in determining the existence, or lack thereof, of an EMC. In the context of the relationship between bodily injury coverage and an automobile accident, there is a bevy of case law setting a "reasonable person" standard on the adjuster in the review of medical records and accident-related information provided by a claimant.The duty of good faith obligates the insurer to make any reasonable settlement offer within the confines of coverage when exercising the same degree of care and diligence as any person would in the management of his own business. In other words, a claims adjuster has a fiduciary duty to their insured client to look out for their best interests. This same duty should apply to the handling of PIP claims.
Practice Tips for Healthcare Providers
Ensure your notes are documented when billing this code in that it specifies the region performed, who performed it (not an LMT), and a specific description of what was done. While there are countless other PIP-related questions to be addressed, these are some of the main ones we are asked about often.
Contact Dolman Law Group for Help With Your PIP Claims
PIP suit clients of the Dolman Law Group Accident Injury Lawyers, PA have no out-of-pocket costs. All attorney fees earned are separate and apart from the benefits, we seek the outstanding bills for services rendered by your medical practice. We handle PIP claims and lawsuits against any and all Florida car insurance carriers.Our PIP lawyers have performed numerous audits of PIP claims for medical providers. Additionally, we have the staff power and resources to consult with a medical provider at their office. We are always happy to review claims at your office as a matter of convenience for you and your staff. In fact, our team will scan all non-payments, denials, and improper reductions and commence work on them at our office. In most cases, we will recover your fees in 60 to 90 days.