Insurer Requests for Written Report From Provider
Florida PIP law requires insurers to provide up to $10,000.00 in medical benefits for “all reasonable expenses for medically necessary medical, surgical, x-ray, dental, and rehabilitative services…” Claiming that the services provided were not reasonable or medically necessary is just one weapon insurance companies use to turn down claims and deny reimbursement to doctors who treat patients after a car crash. To help them use this weapon, the Florida legislature has armed insurance companies with a specific statute – 627.736(6)(b). This section of the law requires doctors to provide insurers with a written report upon request to help them decide whether the services provided were medically necessary or not.
Below we discuss what is required of medical providers under 627.736(6)(b). If you’ve been asked to furnish a written report to the insurance company, or if your claim for reimbursement is being unreasonably delayed, denied, or underpaid, call the Florida PIP law attorneys at Shuster Saben Estevez for help. We’re the leading law firm in Florida when it comes to helping doctors collect from insurance companies on PIP claims. With offices located all over the state, we are here for you when you need us and ready to serve.
The Ins and Outs of 627.736(6)(b)
Florida PIP law requires the insurer to pay 80% of a patient’s reasonable and medically necessary treatment following a car crash. These benefits can be up to $2,500 or as much as $10,000 if the patient had an emergency medical condition (EMC). An insurer’s request for information could be used to determine medical necessity for treatment as well as to determine EMC, so understanding this law is vital not just for reimbursement in general but also for the important step of obtaining reimbursement over the $2,500 non-emergent cap.
In general, medical providers have 35 days from the date of service to submit their claim for reimbursement to the PIP insurer. Upon receipt of the claim, the insurer has 30 days to conduct any investigation it feels it needs and pay the claim if deemed valid. A request for a written report under section 627.736(6)(b) stops the 30-day clock. However, once the doctor provides the written report, the insurer then generally has ten days to pay the claim.
The request for a written report may seem burdensome and inconvenient to the provider, but compliance is mandatory after an insurance company request. The law requires the doctor to report on the history, condition, treatment, dates, and costs of treatment, as well as why the items identified or questioned by the insurer were both reasonable in amount and medically necessary. The doctor must also identify which portion of the expenses was incurred as a result of the injury and must produce and allow inspection and copying of the doctor’s records.
The law requires that the report include a sworn statement by the provider that the treatment or services were reasonable and necessary.
Protections for Providers
Make no mistake that a 627.736(6)(b) request is not only onerous for the provider; it is there for the purpose of giving the insurance company ammunition to deny a claim for reimbursement by determining the service or treatment was not reasonable or medically necessary. However, the law is not without some rights, benefits and protections for the doctor. These include:
- The insurer is required to pay the costs incurred to produce the report.
- Doctors can’t be sued for violating doctor-patient privilege or invasion of privacy when complying with the law.
- The request for a written report from the provider must be made within the 30-day period insurers have to pay a claim. Once they receive the report, they must pay the claim within ten days or it is overdue. Once the claim is overdue, we can seek to force payment through legal means including demand letters, internal appeals, and lawsuits in county court.
- If the insurer requests written reports from providers without a reasonable basis as a general business practice, this amounts to an unfair trade practice under the insurance code.
Let Shuster Saben Estevez Be Your Guide to Requests Under 627.736(6)(b)
Although written reports are mandatory on request from the insurer, you might find it worthwhile to give us a call in this situation. The insurance company might be asking for information that doesn’t fit into the statute, or you might have already sent them everything you have. In situations like this, we can help you craft a reply that tells them so and gives them ten days to pay the claim or face a demand to pay an overdue claim.
If you are having trouble navigating Florida’s PIP law on your own, or if you feel your claim for reimbursement is being unfairly delayed, denied or underpaid, call Shuster Saben Estevez at 877-511-7829 or any one of our many offices located throughout the state. We are here for you and ready to fight for you.
