The PIP Suit Process for Healthcare Providers

November 27, 2017 | Attorney, Matthew Dolman
The PIP Suit Process for Healthcare Providers

Florida PIP law is a fluid and rapidly evolving area that has seen several revisions in recent years.  In the past year, we have posted many articles regarding current trends and topics in Florida’s ever-changing no-fault laws. Our goal is to educate medical providers on the issues so they are better able to formulate intra-office policies to deal with new changes in the law and for us to become a resource of information.

Since we handle PIP claims and PIP lawsuits on behalf of Florida medical providers, I sought to take a step back and explain how the process works, what the provider can expect, fees, expectations, and what providers should look for in determining whether or not a PIP demand can be sent. Florida PIP law mandates that bills are overdue if not paid within thirty (30) days, absent reasonable proof they are not responsible for the claim.

If your bills have been denied or reduced, as reflected on an Explanation of Benefits, or are simply unpaid with no explanation, you have a potential PIP claim. Dolman Law Group can provide critical legal insight throughout every step of the process to attain a favorable outcome.

Pre-Lawsuit Demand Letters Initiate the Claims Process

Before filing a formal Personal Injury Protection lawsuit, there are a few steps that your PIP attorney can take to allow the insurance company to resolve the claim. Per Fla. Stat. 627.736(10), which explains the pre-lawsuit process, we send a demand letter to the insurance company notifying them of the dispute.

The letter also advises that they have 30 days to pay the claim, along with interest, penalty, and postage, or a lawsuit will be filed. If the claim is not paid, then a personal injury lawsuit is filed and the insurer risks exposure to a PIP attorney’s fees. Attorney’s fees are not recoverable if the claim is paid pursuant to the demand letter.

To issue a PIP demand letter, certain documents are required. One of those is an Assignment of Benefits (AOB) and an itemized ledger that specifies specific codes and charges are required before any work can get done. The issues of a particular case may warrant additional documentation, we will advise accordingly. Without an AOB, we cannot do a demand on behalf of the medical provider. If your patient has not signed an AOB, we recommend securing that paperwork as soon as possible.

The Process of Filing a Personal Injury Protection Claim

There are a myriad of issues to explain on this topic, but for brevity purposes, I will keep it short and simple. Once litigation is filed, usually in the Small Claims Division of County Court, the Clerk automatically sets a pre-trial conference date in which the insurance company’s attorney must appear. The majority of newly filed cases will settle at or before the pre-trial conference date, which benefits the provider in that they will quickly receive payment.

For cases that continue past the pre-trial conference date, discovery commences. The discovery process typically involves interrogatories, requests for production, and depositions. We understand that medical providers and billing managers are busy individuals and are often reluctant to sit for depositions and engage in lengthy discovery. Therefore, we try to resolve our cases as quickly as possible to minimize the client’s active involvement so they can focus on treating patients and running offices.

Fees and Settlements in a PIP Lawsuit

First and foremost, medical providers should know that our fees never come out of PIP benefits owed to you. For cases that settle pursuant to the pre-PIP lawsuit demand letter, our fees are simply the statutory 10% penalty (limited to $250.00) and postage. For example, if $800.00 in PIP benefits are recovered, the settlement is as follows:

  • $800.00 in PIP benefits + interest (at 4.75%) to the medical provider
  • $80.00 (10% statutory penalty) + postage reimbursement to us

In cases that settle per a PIP lawsuit, our fees are paid directly to us by the insurance company per Fla. Stat. 627.428. In the same example above, the medical provider would still receive $800.00 in benefits plus interest, and we receive our PIP attorney’s fees separately and apart from benefits. We do not take a portion of the client’s recovery. Insurance companies have an incentive to settle cases on demand, to avoid exposure to PIP attorney’s fees. That is why over half of our cases will settle within 30 days from the time the demand letter is sent.

What to Look For in Explanation of Benefits Paperwork

Medical providers and billing managers must carefully scrutinize all Explanations of Benefits/Reviews that come in. If you see an “allowed amount” as being $0, or anything that indicates the charge will not be paid, mark it for review, as there is a potential issue. If you see office visits being down coded (for example, 99204 to 99202), that is a reduction ripe for demand.

In the event that your patient is sent for an IME and benefits are subsequently suspended, that is a claim ripe for demand. Essentially, anytime the EOBs/EORs indicate no payment you have a likely issue for a PIP demand. Take time to read the explanation code on the EOB/EOR which gives the reasoning for denial. While a small percentage are legitimate denials (i.e., no coverage), the majority are not so when in doubt, ask us.

Medical providers and billing managers should be mindful of when claims are past-due. EOBs/EORs are sometimes not sent and a claim could go unpaid for months and years without explanation. Once 30-35 days have passed, if no payment is received and there are no EOBs/EORs explaining the nonpayment, the claim is ripe for demand. To sum it up, look for denials reflected on the EOB/EOR, down codes, reductions below what is normally expected, IME suspensions, and past-due payments.

Frequently Asked Florida PIP Questions

Can we do our own PIP demand?

The short answer is, yes you can. However, it likely will not be as effective as if a law firm did it. We have skilled Personal Injury Protection attorneys and experienced staff members that know how to perfect the demand letter to minimize flaws, maintain precision, and maintain compliance with the strict statutory rules. Experience tells us that insurance companies are more likely to respond to PIP attorney demands because of the potential for immediate litigation than non-attorney demands. Finally, why take the staff's time and fight with the insurance company? Let us do that.

Why wouldn’t we just bill health insurance for unpaid claims?

Assuming that health insurance exists on a particular claim, the payment is often dramatically lower than the allowable PIP fee schedule. It may not even be paid at all until a deductible is met. The health insurance claims process is lengthy and the appeal process is a nightmare. In contrast, the PIP process is intended to be short.

What about out-of-state insurance policies?

If a policy is written under the laws of another state and the particular insurance company is NOT authorized to write policies in Florida, then the other state’s insurance laws prevail. For example, Erie Insurance writes policies in the Midwest, but not in Florida. So, if your patient’s bills are being sent to Erie for PIP payment (provided the state has PIP), then any denials or issues, would be regulated by the underwriting state, not Florida. We cannot do a demand under Florida’s PIP law because it does not apply. Any litigation would also have to be brought in the underwriting state.

Can a demand be done for Medical Payments benefits?

No. Medical Payments or MedPay is purely contractual coverage and not part of Fla. Stat. 627.736, which governs PIP. Issues involving MedPay are simply breaches of contract and the same pre-lawsuit requirements for PIP do not apply. Therefore, there is no entitlement to interest, penalty, or postage.

How long should the process of a PIP claim take?

Once the PIP demand is sent, a response is expected within 30 days of the insurer’s receipt. If no response is forthcoming, we immediately file a PIP lawsuit. There is no time frame at which a case must settle.

How can we get the documents to you?

We understand that various offices of various sizes have different preferences. Our goal is to make the collection process as convenient as possible. We are equipped and skilled enough to come to your office, audit your files, and collect the work ourselves without much assistance. That way, your staff resources are conserved. We can also accept new PIP work via email or fax, whichever is easiest for the office staff.

How long can we go back to file a PIP claim?

The standard statute of limitations for contract claims is 5 years. For PIP purposes, it is 5 years from the date that the claim is past due, not 5 years from the date of loss. As a cautionary tip, if benefits are exhausted that is often the end of the line for PIP claims.

Why Should I Choose Dolman Law Group?

When an insurance company has unfairly reduced, denied, or ignored your claim for PIP benefits, you need a qualified Person Injury Protection attorney to pursue the appropriate compensation in a timely manner. Dolman Law Group has helped numerous medical providers recover the compensation they are owed during our past decade of service to injured Floridians and the medical providers who treat them.

The PIP attorneys of Dolman Law Group are known as effective communicators who value client satisfaction. We offer the attention of a smaller law firm, but we have access to the resources of a larger law firm. At the provider’s request, we will prepare a monthly or weekly status update of all active cases. The report can be customized to fit your needs.

With the support and expertise of our team available to you, you have a greater chance of recovering the maximum compensation owed. We will work tirelessly on your behalf. You can trust the Personal Injury Protection attorneys of Dolman Law Group to advocate for maximum compensation on behalf of your office.

Contact Dolman Law Group For Help With Your Personal Injury Protection Claim

While there are many other topics to explore and discuss, I hope this article will serve as a general overview of how Florida PIP claims work and how we handle them. Further, our PIP attorneys and staff remain available to audit your billing records to determine the presence and likely success of PIP claims you likely have in your office.

Our team is composed of diligent, detail-oriented personal injury lawyers with over 200 years of combined experience. We specialize in handling disputed Florida Personal Injury Protection claims for medical providers along with other personal injury issues. This experience includes successfully settling complex claims in court, as well as in negotiations.

If you are a medical provider, current or prospective, and have any questions regarding whether or not you have a potential claim, please give us a call. We are here to serve you. You can reach out to our office today to schedule a free consultation to discuss your legal options.

Dolman Law Group Accident Injury Lawyers, PA
800 North Belcher Road
Clearwater, FL 33765


Matthew Dolman

Personal Injury Lawyer

This article was written and reviewed by Matthew Dolman. Matt has been a practicing civil trial, personal injury, products liability, and mass tort lawyer since 2004. He has successfully fought for more than 11,000 injured clients and acted as lead counsel in more than 1,000 lawsuits. Always on the cutting edge of personal injury law, Matt is actively engaged in complex legal matters, including Suboxone, AFFF, and Ozempic lawsuits.  Matt is a lifetime member of the Million Dollar Advocates Forum and Multi-Million Dollar Advocates Forum for resolving individual cases in excess of $1 million and $2 million, respectively. He has also been selected by his colleagues as a Florida Superlawyer and as a member of Florida’s Legal Elite on multiple occasions. Further, Matt has been quoted in the media numerous times and is a sought-after speaker on a variety of legal issues and topics.

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