2013 PIP Reform
Once again, the Legislature – at the request of the insurance companies – has made sweeping changes to Florida’s PIP law. And, once again, the changes are vague, ambiguous, and possibly unconstitutional. The new law, most of which becomes effective January 1, 2013, will lead to much more litigation to properly determine the rights of patients and providers. Below is a synopsis of the important changes.
FS 316.066 has been amended to require use of the long form of traffic crash reports whenever there is any indication of pain or discomfort by any occupant of the vehicles involved. It also required all passengers to be listed. The previous version of the law required the long form only if there was death or personal injury. This is important for a couple of reasons. One, if a person is not listed in the report, they are presumed not to have been in the accident and are not entitled to benefits. It could also preclude a personal injury claim for anyone not listed in the report. Second, the absence of a long form report would suggest that no one at the scene gave any indication of pain or discomfort of any kind.
FS 400.9905 has been amended to provide that all entities that provide medical treatment to PIP patients must be licensed under the Health Care Clinic Act in order to receive reimbursement under PIP unless the entity is exempt under FS 627.726(5)(h). That section provides exemptions to:
Entities wholly owned by medical doctors, doctors of osteopathy, dentists, or chiropractors and their families
Hospitals or entities wholly owned by hospitals
Entities associated with medical schools
FS 626.989 has been amended to create penalties for submitting fraudulent information in connection with the application for licensure or exemption under the Health Care Clinic Act. Previously, no such penalty existed and many unscrupulous providers took advantage of it.
FS 626.9895 was enacted to create the PIP fraud strike force.
FS 627.7311 was enacted to give immediate effectiveness to the changes in the PIP law without requiring the insurance companies to amend their policy forms or to provide notice to insureds.
FS 627.732 (Definitions) was amended to add:
“Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (a) serious jeopardy to patient health (b) serious impairment of bodily functions (c) serious dysfunction of any bodily organ or part.
This section defines “wholly owned” for purposed of licensure or exemption under the Health Care Clinic Act. It is intended to remove “straw man” owners.
FS 627.736(1) was amended to require an accident victim to receive “initial services or care” within 14 days of the accident. The “initial services” can be provided in a hospital or urgent care facility, or by an MD, DO, dentist or chiropractor. Follow up care requires a specific referral for such care by the physician who provided the initial services. Follow up care can be performed by an MD, DO, dentist, chiropractor, physical therapists, PA or ARNP. The section also limits follow up care to entities that are (a) hospitals (b) wholly owned by physicians (c) licensed physical therapists (d) licensed health care clinics that (1) have a medical director (2) have been licensed for 3 continuous years and (3) provide at least 4 of the listed medical specialties. Entities that were previously exempt, or that have obtained their license less than 3 years prior to 1/1/13 will not be eligible to receive PIP reimbursement.
FS 627.736(1) was also amended to potentially reduce the amount of PIP benefits available. Reimbursement for “initial services” and follow up care is limited to $2,500 unless patient had an “emergency medical condition (EMC).” The determination of whether an “emergency medical condition” existed can only be determined by an MD, DO, PA, ARNP or dentist. A chiropractor cannot make this determination. Oddly, the statute does permit a chiropractor to determine that an “emergency medical condition” did not exist.
FS. 627.736(1) was amended to completely remove massage from PIP reimbursement – regardless of who performs it. Furthermore, massage therapists and acupuncturists are prohibited from billing PIP carriers for any treatment whatsoever.
FS 627.736(4) was amended to require the insurance company to provide an EOB detailing any alleged error in the submission of the claim. The provider has the option of resubmitting within 15 from receipt of the EOB.
FS 627.736(4) was amended to allow the insurance company extra time to investigate a claim where it has a “reasonable belief” that fraud has been committed. The insurer has 30 days in which to notify the patient that the claim is being investigated for fraud. The insurer then has 60 to conduct its fraud investigation. No later than 90 days form submission of the claim, the insurer must either pay the claim with interest or deny the claim.
FS 627.736(5) was amended to specifically include the Medicare fee schedule for durable medical equipment. It also allows insurers to utilize Medicare coding policies and payment methodologies to determine reimbursement. This is no doubt at the request of State Farm who uses every Medicare guideline in its reimbursements. Although State Farm recently lost an appeal regarding the use of NCCI edits for past claims, the NCCI coding edits are now effective for PIP carriers. Multiple procedure limitations are likely also usable by the insurers.
FS 627.736(6) requires the insurance company to notify the patient or provider of exhaustion of benefits within 15 days if there is an ongoing dispute. The statute does not provide a remedy for failure to do so. This section also permits examinations under oath of patients as a condition precedent to coverage. Failure to attend will result in denial of coverage.
FS 627.736(7) was amended to include a presumption that failure to attend 2 IMEs is unreasonable and thus a basis for denial of further benefits.
These are just the highlights of complex changes in the world of PIP. I am happy to help sort it out for you. Call now (813) 431-4470.