This law applies to accidents occurring on/after January 1, 2013
Accident victims must receive initial treatment within 14 days of accident or they will NOT be entitled to ANY PIP benefits.
The insured is allowed to seek his/her full $10,000 in PIP benefits only if he/she is diagnosed with an “Emergency Medical Condition.”
Reimbursement for treatment is limited to $2500 unless diagnosed with an “Emergency Medical Condition” by a physician (M.D.), osteopath (D.O.), dentist, supervised physician’s assistant (P.A.), or advanced registered nurse practitioner (ARNP).
“EMERGENCY MEDICAL CONDITION” (“EMC”) is defined as 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: SERIOUS jeopardy to patient health, SERIOUS impairment of bodily functions, SERIOUS dysfunction of any bodily organ or part.
None of the key provisions are defined within the statute, nor are they defined in the American Medical Association’s Guidelines. It is the AMA guidelines that are designed to assist physicians in objectively evaluating a claimant’s injuries and limitations. Without a clear definition of what constitutes “Serious Jeopardy,” “Serious Impairment” or “Serious Dysfunction,” it will be up to physicians and insurance adjusters to make that determination, and as noted above, it is that determination that will decide whether the injured person is entitled to $10,000.00 or $2,500.00 in medical benefits.
A chiropractor is excluded from being able to make the “Emergency Medical Condition” diagnosis. A patient could get chiropractic and other follow-up care up to the $10,000 in benefits if the patient first gets a diagnosis of an EMC from an M.D., D.O., P.A., or ARNP. The chiropractor is then allowed follow-up care for treatment limited to the initial diagnosis up to the full $10,000 in benefits.
If the insured is not diagnosed with an EMC or if the insured only receives treatments from a chiropractor, the patient gets to use up to $2,500.00 in PIP benefits.
As of this new law’s effective date, January 1, 2013, insurance carriers will not be required to amend their policies or to formally notify providers, claimants, or insureds of the change in law or of the change in the terms of their policy.
The insured gets $0 in PIP benefits if he/she seeks treatment beyond the 14 days after the motor vehicle accident.
Massage Therapy and Acupuncture are NOT reimbursable by PIP, even if they are recommended by the treating physician or any other physicians.
Medicare Coding Policies: The bill allows the insurer to use Medicare coding policies and payment methodologies, including applicable modifiers (not utilization limits), to further reduce bills.
PIP payment ledger: While the new law requires an insurer to furnish a PIP log to the insured or provider, it only must do so if, “litigation commences.”
Examination Under Oath: An insured and omnibus insured (passenger) must sit for an Examination Under Oath as a “condition precedent” to receiving benefits.
Like current law, medical benefits will continue to be paid at 80% of all reasonable expenses for medically necessary services. Regarding those medical expenses paid at 80%, the insurer is only required to provide reimbursement for initial services provided by a physician at a hospital or in a facility that owns, or is wholly owned by a hospital, by a physician licensed under Chapter 458 or 459, by a dentist licensed under Chapter 466, or by a chiropractic physician licensed under Chapter 460, or for treatment provided by emergency transport.
For follow up treatment, upon referral by a recognized provider as set forth in the bill, follow up services and care CONSISTENT with the underlying medical diagnosis will be covered, including physical therapy upon referral by a provider as set forth in the bill.
This is another area where potential litigation could exist, as under the language of the bill, follow up services will only be covered if they are consistent with the underlying medical diagnosis. That means that if, on initial examination, the insured only complained of neck pain, yet, after seeking treatment for neck pain, also received treatment for lower back pain, treatment related to the back may not be covered under the policy, nor will diagnostic tests which the carrier feels are unrelated to the initial complaints.
IMEs – Independent Medical Exams (IME’s) continue to be included in the law. However, the law states that the carrier is no longer liable to pay benefits on behalf of any person who unreasonably refuses to submit to an exam or “fails to appear” at an exam. It goes on to state that the refusal to appear at two examinations raises a rebuttable presumption that the refusal was unreasonable.
Tolling of payment of benefits: The insurance company gets an additional sixty (60) days to pay benefits if it “suspects” insurance fraud. There is no definition of what “suspects” requires.
If an insurance company only pays a portion of the claim submitted or rejects the claim, the carrier is required to provide an itemized explanation of benefits due. Upon receiving the explanation, the person making the claim has 15 days to submit a revised claim in order for it to remain considered timely filed.
If the insurance company has reasonable grounds to believe that a fraudulent act has been committed, the insurer is required to notify the claimant in writing, within 30 days after submission of the claim, that the claim is being investigated for suspected fraud. What the insurance carrier is NOT required to do under the bill is to specifically describe the alleged fraud or grounds for the belief that fraud was committed.
Simply asserting that fraud has occurred provides the carrier with an additional 60 days before payment must be made.
Contact Cecere Santana for a free consultation with reference to your case at (800) 75 FL LAW