As , we understand the nuances and intricacies of Florida’s No-Fault Law and the . We are constantly informing 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 are always faced with 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.
Florida PIP Insurance Explained
What is Personal Injury Protection?
PIP stands for Personal Injury Protection, a type of no-fault insurance coverage that pays medical bills and lost wages in the event of a Florida accident. Understanding a Personal Injury Protection claim and PIP law in Florida are key, since this is the main form of insurance coverage for drivers of motor vehicles.
How does PIP work? Is there PIP coverage?
While there are a variety of situations to explore, here are some of the most common that a typical provider is often confronted with.
Was the patient treated within 14 days of the crash?
- If no, automatically no coverage applies.
Practice tip for providers – Make sure your 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 qualifies as establishing treatment within 14 days. See Florida Statute .
If the patient did receive treatment within 14 days, then you will want to know whether or not the patient owned a car. If they did own a car, PIP coverage applies and the claim must be made with your patient’s PIP insurance carrier.
If they did not own a car, you will want to know:
Does the patient live with a relative (blood or spouse) who owns a car?
- If so, then PIP coverage applies and you will make your claim with the patient’s relative’s insurance carrier. Even if the patient was a passenger in another vehicle, they are covered, as long as they either own a vehicle or reside with someone who own a vehicle.
- If not, was the patient a passenger in a vehicle that was involved in the accident? If so, then coverage should apply through the host vehicle and your claim should be submitted to them.
Are pedestrian and bicyclists covered under PIP?
The short answer, it depends. Even if your patient was a pedestrian or bicyclist, you will want to know if they own a car:
- If they do, then they are covered under their own policy.
- If the patient does not own a car, but resides with a relative, then they are still covered.
- If the patient does not own a car, nor resides with a relative who does, only then do they receive PIP coverage from the at-fault driver’s insurance.
Practice tip for providers – Not all patients will have an attorney or want representation, so you need to make sure your intake forms are complete and thorough to establish insurance coverage. You can establish insurance coverage by asking the basic questions above.
Can a chiropractor provide initial care and services?
Yes. Under the Florida PIP statute, initial care and services provided within the first 14 days, after the accident, can be provided by an M.D., D.O., D.C., dentist, hospital, facility owned by a hospital, and emergency medical personnel. The initial care and services may also be supervised, ordered, or prescribed by the aforementioned.
Who can render medical services under Florida PIP law?
Medical doctors, doctors of osteopathic medicine, chiropractors, hospitals, and EMS services. 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.
What is an Emergency Medical Condition (EMC)?
In accordance with , an 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 an EMC be done?
The law does not specifically say. However, as a matter of practice, I believe an EMC should be done after MRI’s and related diagnostics are performed, so that the medical provider can adequately support the EMC conclusion with clinical correlation. Further, I believe it would be wise to correlate all clinical findings and presentation with diagnostic results at the earliest opportunity. On 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 does 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. In turn, this bolsters any argument that the claimant has sustained an EMC, even if the physician did not actually expressly state the words “emergency medical condition.”
Does an EMC have to be established within 14 days of the accident?
No! There is a growing misconception that an EMC determination must be done within 14 days to establish PIP coverage, which is simply not true. The 14-day rule simply opens PIP to at least $2,500 in coverage. The law does NOT say when an EMC has to be provided.
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 is treated 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;
- and, if hospital treatment counts as establishing an EMC.
What form should the EMC take?
Ideally, something more than just a checked box, to avert the insurance company’s suspicion. I believe an EMC should be incorporated into: either an initial office note where a comprehensive examination is done, complete with the patient consultation and MRIs; or, in a subsequent follow-up visit, if MRIs were not previously done. While not required, I highly recommend using the language of the statutory definition to alleviate any ambiguity or lingering questions by the adjuster. In other words, be sure to word your statement about the EMC with similar language to that found in the statute.
What if benefits are limited to $2,500, should we continue billing?
Yes! The same answer applies if PIP benefits are suspended due to an Independent Medical Examination (IME) or peer review. Always keep billing. In the event the EMC is overturned, bills will be paid in the order received.
Does PIP pay for manual therapy vs. massage therapy?
It depends on the carrier. Progressive and USAA routinely deny CPT 97140 (manual therapy) charges on massage therapy grounds, while other carriers pay without much hesitation. We have successfully received payment for providers during pre-suit demand in cases of manual therapy (CPT 97140) denials.
Ambiguities in Florida PIP Insurance
The statute, as it is 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 actually using the words “Emergency Medical Condition.” For instance, if a car accident victim sustains a very serious spinal injury, warranting the need for immediate surgical intervention, will the insurance adjuster deem the condition to be an EMC, even if the treating physician and/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 which meets the requirement of their injury causing serious impairment to a bodily function and/or dysfunction of a body part (as the statutory definition of an EMC defines it). This is readily apparent by the immediate need for surgery. Does Florida PIP laws require the handling claims adjuster to make a reasonable interpretation of whether an EMC exists based on the available medical records? I would contest that physicians are not trained in diagnosing or utilizing the term EMC in medical school or residency. This is a term created by the Florida legislature during an obvious victory for the insurance industry.
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 verdict/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. 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 is very clear as to what happens when there is a determination of no EMC ($2,500 in benefits). When a physician determines that there is an EMC, $10,000 in benefits is available. What happens when a physician fails to make a determination on whether the injury meets the threshold of an EMC? Florida Statute and case law (as of date) is silent on what shall occur when no determination as to the existence of an EMC is made.
The statute, as it presently stands, leaves a number of issues unanswered with little, if any, guidance for Florida medical practitioners. Again, we are left to inquire what duty, if any, 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 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. I would presume that this same duty applies to the handling of PIP claims, so it should be interesting to see how the courts ferret out this issue.
Practice tip for providers
Make sure 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 countless other PIP-related questions to be addressed, these are some of the main ones we are asked about often.
Tampa PIP Suit Attorneys
If you are a medical provider or medical manager, and have a PIP-related question, please do not hesitate to contact us. We can be reached at 727-451-6900 or by emailing .
PIP suit clients of the Sibley Dolman Gipe Accident Injury Lawyers, PA have no out of pocket costs. All attorney fees earned are separate and apart from the benefits we seek and the outstanding bills for services rendered by your medical practice. We handle PIP claims and lawsuits against any and all Florida car insurance carriers.
We 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. Thus, we are always happy to review claims at your office as a matter of convenience to 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. If you are not sure whether your PIP case requires an attorney, checkout our help resource: “When Do You Need to Hire a Personal Injury Lawyer?”