As Florida PIP law attorneys, we understand the nuances and intricacies of Florida's no-fault law and Florida PIP statutes. We continually inform our clients, medical providers and colleagues about the various areas of PIP law that apply to them.
I believe only medical providers, including billing managers, should have a basic understanding of PIP because they are receiving reimbursement for their services.
In our practice, we receive questions from the same subject areas: PIP coverage, physical and manual therapy, and what is an emergency medical condition (EMC).
So, a useful refresher can benefit everyone. If you need the services of a PIP attorney to help you with the process of applying for benefits or to help you obtain benefits from an insurance company that denied your claim, contact the PIP attorneys at Dolman Law Group. .
Florida PIP Insurance Explained
PIP stands for Personal Injury Protection, a type of no-fault health insurance that covers medical expenses, lost wages and other economic losses in the event of a Florida accident.
Florida is a fault state that requires its drivers to purchase personal injury coverage to allow them to recover compensation for damages caused by car accidents.
a car accidentpay for the exorbitant expenses incurred. Pays up to $10,000 worth of applicable damages the expenses PIP covers:
of60% of lost income
Funeral expenses
Ambulatory services
Hospital expenses
Surgical and rehabilitation costs
Understanding a personal injury protection claim and PIP laws in Florida are important to both car accident victims and insurers. Most car accidents in Florida.
How does personal injury protection insurance work?
The specifics and intricacies of who and how can receive PIP benefits. These are the details you need to know as outlined in Florida PIP statute 627.736.
The severity of the car accident injuries, how long it takes them to receive medical treatment, and Were they in the car, it may change whether one can receive PIP benefits.
The following are some of the details that may affect whether a person can receive PIP benefits:
Did the car accident victim receive medical attention within 14 days?
to receive medical treatment from a health care professional within 14 days of a motor vehicle accident.
The idea behind this rule is that if the injury is serious, the victim will go to a hospital for treatment.
prevents them from receiving benefits that the serious injury does not require. If a car accident victim does not receive medical treatment within 14 days of the accident, they will not have access to PIP coverage benefits.
Health care providers should ensure that their intake forms and patient consultations are covered whether or not the patient received emergency service from a primary care physician, hospital, walk-in clinic, or roadside.
Regardless of whether your patient is a hospital , emergency transport and initial services and care provided by the person or institution providing the treatment are eligible to establish treatment within 14 days. Florida Statutes 627.736(1)(a)1.
Does the car accident victim have a car?
If the patient had received treatment within 14 days, the PIP solicitor will want to know whether the patient has a car.
PIP coverage applies if they own a car, and the victim must file a claim with your patient's PIP insurance carrier.
Motor vehicle owners can avail PIP benefits, as they are required to purchase PIP insurance to cover their vehicles. However, if the victim of a car accident does not own a car, obtaining PIP benefits can be challenging.
You may be a victim of a car accident and may need compensation for damages caused as a passenger during a car accident.
Without your own PIP insurance, you can get coverage from a relative you live with who has PIP coverage. You can file a claim with their insurance provider and recover compensation for the loss.
If you were a passenger in a vehicle involved in a car accident, you can make a claim on driver's PIP insurance to receive benefits for car accident injuries.
Are pedestrians and cyclists covered by PIP?
Pedestrian and bicycle accidents can result from the negligence of a driver who breaches the duty of care.
Whether they can get compensation for damages caused by a car hitting them depends on whether they own the car or not.
As mentioned above, they can get coverage if they own a car and have bought PIP insurance.
If not, they can claim on PIP insurance of their relative. If neither of these situations apply to pedestrians or cyclists, they can file a claim with the at-fault party's insurance company.
Not all patients will have an attorney or want representation, so providers must ensure that their intake forms are complete and thorough in establishing insurance coverage.
A provider may establish insurance coverage by asking questions about whether the pedestrian or cyclist owns a car or if they live with a relative who owns a car.
Who Can Provide Medical Services Under Florida PIP Law?
Medical doctors, doctors of osteopathic medicine, hospitals and EMS services can all provide medical services.
The amended Florida PIP statute does not allow a massage therapist or acupuncturist to bill a PIP for medical services provided. In addition, massage therapy and acupuncture services are not covered even if a physician is supervising such services.
Under Florida PIP law, PIP insurance covers initial care and services provided by an MD, DO, DC, dentist, hospital, hospital-owned facility, and emergency medical personnel within 14 days after the car accident. Initial care and services may be supervised, ordered, or determined by those described above.
What is an emergency medical condition (EMC)?
According to Florida Statute 395.002(8), an emergency medical condition (EMC) is a medical condition manifested by acute symptoms of sufficient severity, which may include severe pain, such that without immediate attention any consequences can be expected. Of the following:
Serious risk to the patient's health
Serious impairment to physical functioning
Severe dysfunction of any bodily organ or part
An insurance provider is required to provide PIP benefits only if the car accident victim suffers an EMC accident Directly fromA healthcare provider will go through all the diagnostic tests to determine whether or not the car accident injuries are likely to cause the damage described above.
They can then include this in their reports to indicate to the insurance provider that the car accident victim is entitled to PIP benefits.
When should a health care professional decide whether a patient has EMC?
Although the law does not specify, the medical provider should determine an EMC following the MRI and associated diagnosis, so that they can adequately support the EMC findings with clinical correlations.
It is wise to correlate all clinical findings and presentations with clinical outcomes at the earliest opportunity.
discogenic disc injury , it may be wise to involve an interventional pain physician (anesthesiologist or physiotrist) sooner rather than later.
If the client's pain and clinical presentation do not improve within a limited period of time (three months) and the injection fails to reduce symptoms, it will be very easy for the interventional pain physician to conclude that the auto accident Have met the victim. EMC threshold.
A patient who has failed conservative care and injection therapy should be evaluated by a surgeon, as evidenced by an inability to improve after all less restrictive measures aside from surgery.
This gives credence to any argument that the claimant has sustained an EMC, even if the physician did not explicitly state the words "emergency medical condition".
Should the EMC be installed within 14 days of the accident?
To receive PIP benefits, you need two things: Medical treatment within 14 days There is a growing misconception that an EMC determination must be made within 14 days to establish PIP coverage, which is not true.
The 14-day rule opens the PIP to at least $2,500 in coverage. The law does not say when EMC has to be provided.
Although your doctor will be able to determine that you suffered an EMC after your first visit for medical treatment, you may experience an injury with delayed symptoms.
The severity of the injury may not become apparent until the 14 days required to seek medical attention. If your car accident injury escalates to EMC, you should visit your healthcare provider again so they can make a record of your condition in order to receive PIP benefits.
How does EMC cutoff work?
It is a black and white field with some shades of grey. Simply put, PIP in Florida is limited to $2,500 if treatment occurs within 14 days but no "medical emergency" exists.
Note, however, that such a determination must not be made within 14 days.
Similarly, if treatment occurs within 14 days and the patient is diagnosed with an "emergency medical condition," the PIP is limited to $10,000. Again, EMC should not be made within 14 days. The gray area is activated when the patient receives treatment within 14 days, but:
says nothing one way or the other about
the
EMC
counted
as establishing EMC
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What form should I take to EMC
Ideally, your health care professional should note the EMC as more than just a check box to allay the insurance company's doubts.
An EMC should be included in the initial office note where a comprehensive examination is performed, completed with patient consultation and MRI, or at a later follow-up visit if MRI was not previously performed.
Using the language of the statutory definition is highly recommended by insurance adjusters.
In other words, be sure to write your statement about EMC in language similar to that found in the statute.
If the pip profit is reduced to $2,500, should billing continue?
Car accident victims must always continue billing, whether PIP benefits are capped at $2,500 or $10,000.
This also applies if PIP benefits are suspended due to an independent medical examination (IME) or peer review. In case of EMC reversal, the bills will be paid in the order received.
Does PIP pay for manual or massage therapy?
Your PIP insurance manual or massage therapy it depends on the insurance carrier.
As with all insurance plans, PIP coverage depends on what is agreed upon by the insurance company and the underwriter.
For example, Progressive and USAA routinely deny CPT 97140 (manual therapy) charges based on massage therapy, while other carriers charge without hesitation.
Dolman Law Group successfully obtained payment from providers for clients during pre-suit demands in manual therapy denial cases (CPT 97140).
Ambiguity in Florida PIP Insurance The
PIP statute as written fails to state whether an insurance claims adjuster has any responsibility or duty to determine whether an EMC is in the absence of a qualified physician by using the words "emergency medical condition." exists or not.
For example, will the insurance adjuster consider the situation to be EMC if a car accident victim has a very severe spinal injury that requires immediate surgical intervention?