new banner2

PIP: What is the current status and what are the coming changes that affect LMTs?

 

By, Paul Watson Lambert, General Counsel

 

 The legislature passed a bill reforming the automobile insurance statutes on October 5. The House bill, HB 13C, passed on a vote of 105 to 4. The Senate vote was unanimous at 37 to 0. The Governor signed the bill into law on October 11. Following is a discussion of what changes the bill makes and some tips for LMTs to follow when treating patients injured in automobile crashes during the period that PIP is repealed and filing PIP claims for treatments after PIP is reenacted.

 

 The No-Fault Law, of which PIP is one part, was repealed effective October 1, 2007 by operation of the “sunset” provision enacted by the legislature in 2003.

 

 HB 13C re-enacts the repealed portions of the Automobile No-Fault Law, including the PIP statute, effective January 1, 2008.

 

 That means that there is no No-Fault Law and no PIP law until January 1, 2008. It is left to the courts to rule on the effect on claims and PIP suits pending on October 1. One thing is certain, there is no law requiring PIP coverage or governing PIP claims between October 1 and January 1. The statutory procedures for filing, processing and payment of claims disappear with October 1 sunset.

 

 During the period between October 1 and January 1 some drivers may choose to purchase or maintain a “voluntary PIP policy.” Some drivers may choose not to carry a voluntary PIP policy.

 

 During the period between October 1 and January 1 the voluntary PIP policy contracts will govern how claims are processed and paid. The policies may contain specific provisions for arbitration, peer review, claims submission and more. LMTs should carefully weigh the decision to take an assignment of the claims. By taking an assignment on a claim under a voluntary PIP policy the LMT accepts all of the PIP policy contract limitations and provisions. LMTs should consider treating patients with voluntary PIP policies under letters of protection signed by both the patient and the patient’s attorney.

 

 Following are tips for negotiating the period between October 1 and January 1 and a discussion of the new provisions in the PIP statute which take effect on January 1.

 

Practice tips for the period of October 1, 2007 – January 1, 2008:

 

During the period between October 6 and January 1, 2008 -- An LMT should get guaranteed proof from a patient presenting with car crash injuries during this time period as to who involved in the accident has coverage either under a PIP policy that remained in effect after Oct. 1, or a PIP policy voluntarily purchased after October 1 or a health care policy if there is no PIP policy coverage. In any event, the LMT should make it clear to the patient that the patient is responsible for payment of the treatments.

 

 During the period of October 1 through January 1, all at fault drivers are subject to bodily injury suits. An LMT should make clear that the patient is responsible to pay for treatments directly to the LMT during this period. If the patient intends to file a law suit against the driver who caused the injuries, then the LMT should obtain a letter of protection from the attorney representing the patient assuring the LMT payment for the services when the case is completed.

 

 Some patients may choose to purchase PIP insurance on a voluntary basis between the period of October 1 and January 1. Following are some tips for treating patients with either voluntary PIP coverage or other health coverage during the October 1- December 31 period

 

 1. Require patient to provide proof of coverage or payment guarantee.

 

2. Do not take assignment of benefits.

 

3. Patients who purchase voluntary PIP or voluntary medical payments coverage policies which may authorize direct payment of LMT bills. However, accepting direct payment may carry a lot of strings attached. However, balance billing is not prohibited during the repeal period.

 

 4. Health insurance may be billed if there is no other insurance available. 

 

 5. Services are billed in the same manner as in non-auto tort cases, such as slip and fall and premises liability cases. Letters of protection with attorneys are important to insure your payment on these claims.

 

Following are tips for treating patients who have no auto or health insurance during:

 

 1. For patients at fault for the accident, the only option is direct payment from the patient.

 

 2. For patients not at fault, the options are direct payment at the time of service or to bill services under a letter of protection.

 

  • 3. Determine if there is insurance available from the at fault party.
  • 4. Determine the limit of the at fault party’s insurance liability coverage.

 

5. Determine if there are issues of fault and liability that would decrease the patient’s recovery.

 

6. Determine if there are issues of causation of the injury and whether the treatment is for the injury or for pre-existing conditions that would reduce the patient’s recovery.

 

7. Determine if there are other health care providers with letters of protection against the same recovery amount.

 

8. Determine if there is a hospital lien that takes priority over a letter of protection.

 

9. Determine if there is a health insurance lien that takes priority over a letter of protection.

 

10. Determine whether the patient’s attorney can be trusted to:

    • 1. Provide the information necessary to evaluate the chances of a recovery under the letter of protection;
    • 2. Honor the letter of protection without litigating my claim;
    • 3. Follow through with the case until completion; and 
    • 4. Obtain a sufficient recovery to satisfy the patient and pay the bills.

WHAT IS NEW EFFECTIVE JANUARY 1, 2008?

 

What remains unchanged

 

 The “old No-Fault Law including the PIP statute” is reenacted effective January 1, 2008 with some changes discussed below. What is not changed are the requirements for signing the acknowledgement and disclosure forms, the patient treatment logs, the claim filing time limit periods, the authority for insurers to request information, IMEs, demand letters, collection of the 20% co-payments, the $250, $500 & $1,000 deductible amounts and the procedures for filing PIP suits on unpaid claims.

 

What is new

 

1. A medical fee schedule;

2. Limits on PIP claims by licensed clinics;

3. A limitation on death benefits to the lesser of $5,000 or the remainder of unused PIP benefits per individual;

4. A set aside of $5,000 by PIP insurers of benefits for allopaths, osteopaths or dentists treating PIP patients in hospital emergency rooms or in hospital care;

5. Authorization to file PIP claims electronically;

6. Extension of the time within which insurers must respond to demand letters to 30 from 15 days;

7. Authorization to the Attorney General to investigate and initiate actions against PIP insurers which fail to pay valid claims with such frequency so as to constitute a general business practice; and

8. A requirement that all PIP suit claims by a person relating to a single crash be consolidated into one suit.

 

 Since provider fees are set by the fee schedule, the issue of what constitutes a reasonable fee should no longer be an issue for litigation thereby reducing the number of PIP suits.

 

 What remains to be litigated is whether an injury is related to an accident, whether medical treatment is necessary, whether the correct CPT code is used or whether the claims are properly filed.

 

Medical Fee Schedule:

 

Effective January 1, 2008, physicians, LMTs, hospitals and other health care providers will be paid at 80% of 200% of the 2007 Medicare fee schedule without regard to federal limitations imposed on the Medicare system. Hospitals and providers will use the Medicare fee schedule CPT codes for services rendered. Services which do not have a corresponding Medicare CPT code will be paid at 80% of the Workers’ Comp fee schedule. The providers are required to collect the remaining 20% from the patients. Services that are not included in either fee schedule “are not required to be reimbursed by the insurer.”

 

It is important to note that HB 13C specifically provides that the PIP statute as amended does not allow the insurer to apply any limitation on the number of treatments or other limits that apply under Medicare or workers' compensation. An insurer must reimburse a provider who lawfully provided care or treatment under the scope of his or her license, regardless of whether such provider would be entitled to reimbursement under Medicare due to restrictions or limitations on the types or discipline of health care providers who may be reimbursed for particular procedures or procedure codes. In other words, the Medicare Fee Schedule and the Workers’ Compensation Fee Schedule are used only for the values assigned to the respective reimbursement codes. This is an important provision insisted upon and lobbied solely by the FCA and FSMTA lobby teams. This allows chiropractic physicians and LMTs to be reimbursed without limitations imposed by the Medicare regulations or the Workers’ Compensation Law.

 

The applicable schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect at the time services, supplies, or care were rendered and for the area which such services were rendered, except that it may not less than the applicable 2007 Medicare Part B fee schedule medical services, supplies, and care subject to Medicare Part B. This means that the fees will rise with any increases in the Medicare Part B schedule, but cannot be lower than the fees set in the 2007 schedule in the event that CMS reduces the fees below those set in the 2007 schedule. This “2007 lock in provision” is another important provision insisted upon and lobbied solely by the FCA and FSMTA lobby teams.

 

 HB 13C does not specify whether an insurer is required to pay the fee schedule amount for participating or non-participating providers.

 

 

Limitations on which providers may be reimbursed

 

 Under the “old PIP statute,” Insurers were required to reimburse any person, even faith healers, providing treatment for medically necessary injuries related to an accident

 

 Under HB 13C insurers are still required to pay 80% of expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices, and medically necessary ambulance, hospital, and nursing services.

 

However, reimbursement shall now be paid only for such services and care that are lawfully provided, supervised, ordered, or prescribed by Florida licensed allopathic, osteopathic, chiropractic or dental physicians.

 

 Therefore, therapies prescribed or ordered by a Florida licensed allopathic, osteopathic, chiropractic or dental physician to be performed by an LMT employed by a physician or in an independent practice are reimbursable.

 

Limitations on non-doctor owned licensed clinics

 

 Non-health care provider owned clinics must be licensed by the Florida Agency for Health Care Administration. HB 13C limits payments to these licensed clinics unless they meet certain criteria. Some LMTs are employed by licensed clinics.

 

 For a licensed clinic to qualify for reimbursement of PIP claims, the licensed clinic must:

 

1. Be accredited by the Joint Commission on Accreditation of Healthcare Organizations, the American Osteopathic Association, the Commission on Accreditation of Rehabilitation Facilities, or the Accreditation Association for Ambulatory Health Care, Inc.; or

 

2. Have a medical director who is a Florida licensed allopath, osteopath or chiropractor; and

 

a. Has been continuously licensed for more than 3 years, or

 

b. Is a publicly traded corporation; and

 

c. Provides at least four of the following medical specialties:

 

  • (i) General medicine.
    • (ii) Radiography.
    • (iii) Orthopedic medicine.
    • (iv) Physical medicine.
    • (v) Physical therapy.
    • (vi) Physical rehabilitation.
    • (vii) Prescribing or dispensing outpatient prescription medication.
  • (viii) Laboratory services.

HB 13C authorizes the Financial Services Commission to adopt forms that must be used by an insurers to determine whether PIP claims submitted by providers listed in the amended PIP statute are authorized to submit PIP claims.