Folks, Big Insurance continued their “takeaway” of rights for their insureds (your patients) in 2015 with the gifts given to insurance carriers with the 2013 amendments to Florida Statute 627.736, also know as “The PIP Statute”. These amendments resulted in medical providers getting reimbursed less, or not at all, on PIP claims for auto-related medical treatment, services, and supplies. Here are the three most important issues that we saw litigated in the court system in 2015…and they are sure to be litigated in 2016.

1. Emergency Medical Condition: By now, you should all be aware that a plain reading of the law states that every insured gets $10,000.00 in PIP benefits unless the treating doctor finds that there is no Emergency Medical Condition (“EMC”). However, it is equally “obvious” that the legislature did not intend the law to allow this practice, because the entire intent of “limiting” PIP benefits to $2,500 was to curb “abusive practices” of “unnecessary treatment” of accident patients. Allowing treating doctors to make this judgment is like “giving the fox the keys to the henhouse.” Therefore, as many of you may have envisioned, the judiciary has, pretty much, ruled against us on this issue with respect to the “plain reading” of the statute argument. Personally, my law firm never made this argument, not because it is legally incorrect, but because most judges are just not going to buy it, irrespective of a straight reading of the law. However, for other lawyers in Florida who did make this argument to judges in 2015…they created unfavorable case law (unless their intent WAS to make bad case law and take the issue up on appeal). Who knows? Either way, the preferred method that we recommend is to just get an EMC from a medical provider who is allowed to render such a finding, when you feel such a condition is present. I also recommend sending the written finding of the EMC to the carrier upon your receipt of same…even though the statute does NOT require you to do so. I will comment on this sub-issue in a future blog (it needs more time to be fully explained and you folks still have too much Holiday Shopping to do and New Year’s Ever preparation!).

2. 14-day rule: First, the good news: According to many of my clients, this rule has not affected a significant amount of their work. This is probably because a) doctors and lawyers have done a good job at getting the word out that accident victims must receive treatment within 14 days of their crash; and, b) the majority of accident victims still treat within 14 days. Now, the bad news: this arbitrary law also has been upheld, by and large, in 2015. I haven’t seen any case law precedent striking down this rule, however, I know that the rule is being appealed in at least one circuit in Florida. Interestingly, I have seen some of my clients denied payment because their treatment of a patient did not begin within 14 days of the crash, BUT the carrier was not aware that the patient went to the hospital within 14 days and the hospital did not submit its bill prior to my client submitting its bill. The point: do not take an initial denial of payment, based on 14 days of “no treatment” as a final result that you will not get paid. However, you may shoulder a greater burden for your bills to get paid by tracking down (with your patient) whether they got initial treatment prior to your first date of service with the patient. If their are any developments in the courts with this rule, I will report on same.

3. Improper fee schedule reductions: I’ve preached since 2010 not to accept less than 80% reimbursement of your submitted bills. If you are, you are doing the insurance carrier’s bidding to your own detriment. Frankly, I don’t fault you. The misinformation doled out by Big Insurance confused most doctors…and even most lawyers (including many who call themselves “PIP specialists“) on this issue. Truth is, in 2015, Shuster & Saben recovered more money for our clients, based on improper “fee schedule” payments, than any other year. While many carriers are entitled to pay you the lower reimbursement rate (80% of 200% of Medicare Part B) instead of the “default” payment (80% of your usual and customary charge in the local medical community), others are not! The majority of money that we recovered in 2015 was for our clients who already had their files reviewed once and that lawyer missed the improper payments that we found on our follow-up review. This audit of your closed files is FREE with no obligation. Plus, our clients all got 100% of the benefits that we recovered for them. This is still the fastest, easiest, and most efficient way to get the money that you are owed…and this will continue into 2016.

Shuster & Saben has offices throughout Florida and file our cases anywhere YOU practice. Contact us to help your medical practice with your PIP claims.

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