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The PIP Suit Process for Healthcare Providers

Florida PIP law is a fluid and rapidly evolving area that has seen a number of 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 lawsuits on behalf of many 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.

Pre-Suit Demand Letter

Per Fla. Stat. 627.736(10), which explains the pre-suit process, we send a Demand Letter to the insurance company notifying them of the dispute and advising 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, than a lawsuit is filed and the insurer risks exposure to attorney’s fees. Attorney’s fees are not recoverable if the claim is paid pursuant to the demand letter.

PIP Litigation:  The Process

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; in the form of interrogatories, request 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

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-suit 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 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 attorney’s fees separate 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 on attorney’s fees; that is why over half of our cases will settle within the 30 days from the time the demand letter is sent.

What to Look For

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. If 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 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 manager 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 has 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, look for down codes, look for reductions below what is normally expected, look for IME suspensions, and look for past-due payments.

Frequently Asked Florida PIP Questions

Can we do our own PIP demand? – Short answer, yes you can. Will it be as effective as if a law firm did it, most likely not. We have skilled 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 attorney demands because of the potential for immediate litigation than non-attorney demands. Finally, why take the staff time and fight with the insurance company? Let us do that.

Why wouldn’t we just bill health insurance for unpaid claims? Assuming, health insurance exists on a particular claim, the payment is often dramatically lower than the allowable PIP fee schedule and 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; 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, than the other state’s insurance laws prevail. For example, Erie Insurance writes polices 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 a 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-suit requirements for PIP do not apply. Therefore, there is no entitlement to interest, penalty, or postage.

What documents do you need for a PIP demand? 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, get it done!

How long should the process 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 litigation and there is no time frame at which a case must settle; it varies.

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 will I know what’s going on in our cases? Client satisfaction and communication is key in this business. 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.

How long can we go back to file a 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.

Contact Sibley Dolman Gipe Accident Injury Lawyers, PA

While there are many other topics to explore and discuss, I hope this article will serve as a general overview of how PIP claims in Florida work and how we handle them. 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.

Further, our 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 very office.

Sibley Dolman Gipe Accident Injury Lawyers, PA
800 North Belcher Road
Clearwater, FL 33765

Florida Personal Injury Protection