Numerous times a week I speak to medical billing managers and physicians who will say to me, “I stopped billing, because benefits were exhausted”. So what does it truly mean to have “benefits exhausted”?
Florida Statute 627.736 (Florida No-Fault Statute) requires Florida drivers to have PIP coverage. The statute reads:
(1) REQUIRED BENEFITS.—An insurance policy complying with the security requirements of s. 627.733 must provide personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle, passengers in the motor vehicle, and other persons struck by the motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle, subject to subsection (2) and paragraph (4)(e), to a limit of $10,000 in medical and disability benefits and $5,000 in death benefits resulting from bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as follows:
So what does this mean to you? To explain it, first Medical Payments Benefits coverage needs to be explained. Medical Payments (Med Pay), unlike Personal Injury Protection (PIP) is based in the insurance contract. Meaning, what controls the payment of Med Pay is based in each individual contract. That can make for varied applications, per patient. Med Pay coverage can go as high as the person essentially is willing to spend each month (i.e $100k in Med Pay). PIP coverage ($10k per incident) covers 80% of a “Reasonable Fee” (Reasonable fees will be discussed in another post). Medical Payments coverage covers the remaining 20% of a “Reasonable Fee”. When PIP benefits are exhausted however, Med Pay then pays 100% of the “Reasonable Fee”, until Med Pay exhausts.
Unlike PIP benefits which require interest payments for all late payments, the contract (Insurance Policy) controls whether you get interest on late Med Pay payments. It has yet to be seen a contract that gives interest for Med Pay.
So again, when an adjuster tells you “Benefits are exhausted” what does it truly mean? What the insurance company is saying is, they paid you everything they had to pay you. But what does that mean? At that time you hear them say benefits are exhausted, and choose to stop billing, you are taking the insurance company at its word. DO NOT DO THAT. If you have never seen the insurance contact to verify the policy limits, how can you know how much Med Pay this person has? If other providers were truly getting paid? If the other providers were not getting paid too much?
In order for an insurance company to truly exhaust benefits they could not have made any “gratuitous payments”. A gratuitous payment is, essentially, any payment made by an insurance company on a claim that should not have been paid, or paid over the amount that is “reasonable”. Meaning scenarios such as an insurance company paying a bill that was received in excess of 35 days past the date of service would be gratuitous. Another common scenario is when a certain CPT code is paid in excess of the fee schedule for that particular year. Even if the amount is small (a few dollars) it is actionable. You should send a demand letter for that money. Also an insurance company paying duplicate payments for dates of service would also be considered gratuitous. Remember if the insurance company is found liable for payments at ANY amount, they are responsible for paying all legal fees. If it is found out through a demand letter and/or filing a lawsuit (costs of suit will never be asked of you) the insurance company properly paid your claim, then you can close the file in the office knowing you have gotten everything you deserve.
Many insurance companies try to get law firms to drop their claims for “benefits exhausted”, however at Sibley Dolman Gipe Accident Injury Lawyers, PA we take the extra time to request and review EVERY SINGLE PAYMENT, made to every other provider that the insurance company claims they paid to ensure that they paid them 100% accurately. We even request copies of cashed checks. At Sibley Dolman Gipe Accident Injury Lawyers, PA we do not take the insurance company for their word like other firms. When Sibley Dolman Gipe Accident Injury Lawyers, PA tells you benefits are exhausted, you can know truly that they are. If an insurance company is telling you that benefits are exhausted, continue to bill the insurance company, contact Sibley Dolman Gipe Accident Injury Lawyers, PA at 727-222-6922 or [email protected] and let us take a look at the file to ensure they are telling you the truth.
Sibley Dolman Gipe Accident Injury Lawyers, PA
800 North Belcher Road
Clearwater, FL 33765