After someone is injured in a Florida accident, the injured party may be required to file an insurance claim to pay for medical treatment. Many are often confused when requesting 627.736(6)(b).
Thus, these documentation requests are often ignored. If the request goes unanswered, the provider's bills are not technically "overdue".
The personal injury attorneys at Dolman Law Group can help you file the proper paperwork and expedite the claims process.
If you have questions about the purpose of a 627.736(6)(b) request, you can find more information below. Dolman Law Group also offers free consultations if you are interested in discussing your issues in more detail.
To contact Dolman Law Group, you can either call our office at 727-451-6900 or fill out our online contact form.
627.736(6)(b) What is a request?
can be found in Florida's personal injury protection (“PIP”) statute
Florida statute 627.736(6)(b) states in part, “Each physician, hospital, clinic, or other medical institution on which the claim for personal injury protection insurance benefits is based, any construction, services, or accommodation in respect of that or any other injury, or in respect of a condition claimed to be connected with that or any other injuryshall, if requested by the insurer against whom the claim is made, submit a written report of the history, condition, treatment, dates and cost of such treatment of the injured person and items identified by the insurer in reasonable amounts and medically EssentiallyPIP
, the law gives insurers the ability to delay claim payment by requesting documentation that they believe provides a basis for how the treatment provided was medically necessary This statutory instrument prevents the insurer from paying benefits to them.
The first was designed to provide a mechanism to investigate any frivolous claims. Yet, it seems that insurers are using this tool to delay and deny claims instead.
Insurance companies use 627.736(6)(b) requests as a delaying tactic
. In a typical Florida PIP claim, the medical provider must submit its bill to the insurance company within 35 days from the date of service.
After this, the insurer has 30 days to conduct its investigation and pay the claim.
If they don't pay after 30 days have passed, the bill is overdue, and the provider can send a demand letter to the insurance company for the overdue bill.
If, however, the insurer makes a written 627.736(6)(b) request in response to the submitted bill, the 30-day time to pay the claim is essentially "stopped" until the provider produces the requested documents.
does not. Once a provider sends the requested material to the insurance company, the PIP statute requires the insurer to bill the provider within 10 days of receiving the requested document.
A (6)(b) Ignoring the request does not make your problem go away
. If the medical provider neglects to respond to this statutory request and initiate the demand process, it causes significant problems.
Specifically, as stated above, the insurer's obligation to pay within 30 days of intimation of the bill is put on hold unless their request is honored. If the request is never attended to, the bill is not overdue and demand letter on that claim
(6)(b) It is important for medical providers to be aware of the request so that they can ensure that their bills are paid.
be done immediately. In most cases, these requests are found in the "Clarification" section of the provider's explanation of benefits. In other cases, the request may be made after the provider has sent a demand letter to the insurer.
Whether you receive a (6)(b) request in an explanation of benefits or in response to your demand letter, providers must take the request seriously. No matter how vexing the request for additional documentation may be, providers are required by law to respond, or they may not be able to recover their benefits.
The cost associated with sending documents should not be a concern. This section of Florida's PIP statute mandates that the person requesting such records shall pay all reasonable costs associated therewith.
Thus, anytime a provider sends documentation to an insurer in connection with a (6)(b) request, providers must also submit an invoice for any costs incurred.
(6)(b) Caslow's current position in Florida. In
a decision dated August 31, 2016, the Fourth District Court of Appeals established a precedent emergency medical condition determinations and (6)(b) requests.
Matter of the Medical Center of Palm Beach d/b/a Central Palm Beach Physician & Urgent Care, Inc.
Court to give opinion on the issue of EMC. This means that for the time being, this matter is the governing law throughout Florida.
(6)(b) Understanding the Implications of the Florida Court's Decisions on Requests The
case states that "the issue at hand is whether a qualified medical provider must determine whether under Florida's PIP statute, for benefits in excess of $2,500 An emergency medical condition exists.
Stated another way, if there is either no determination that the insured has an emergency medical condition or there is a determination that the insured does not have an emergency medical condition, whether the PIP Benefits under U.S. would be limited to $2,500."
In addition, the case continues “We find that the statute requires a determination of an emergency medical condition for benefits of up to $10,000.
In addition, we find that there is no determination that the insured will be eligible if either has an emergency medical condition or it is determined that the insured does not have an emergency medical condition, benefits will be limited to $2,500.
For a free legal consultation 866-481-5347
,Understanding the Context
The facts of the case may sound very familiar to you and your medical office. They are:
"Carmen Santiago, the insured, was injured in a motor vehicle accident. She went to an emergency care center because of pain in the cervical region and right shoulder.
The doctor referred him to an appellant for physical therapy. Appellant then billed Appellant USAA, the insurer, for payment, but USAA did not provide any additional payment, explaining that in accordance with section 627.736(1)(a)(4), Florida statute, the $2,500 under the policy Reimbursement had already been made.
USAA requested that the appellants provide a "determination of the patient's emergency medical condition by an authorized provider" so that USAA could make any additional reimbursement decisions.
Appellant sued USAA for breach of insurance contract by failing to issue full payment for the medical treatment appellant provided. Later, the appellant sent USAA a note from Dr. Chang, the insured's treating physician, stating that he had deemed the insured to have an emergency medical condition.
Upon receipt of this document, USAA paid all outstanding charges under the policy up to the limit reached.
USAA moved for summary judgment, which the trial court granted, finding that the provisions of section 627.736(1)(a)(3)-(4) limit medical benefits to $2,500 unless determined Does not happen that the insured had an emergency medical condition. ,
The trial court also determined that USAA reasonably requested that appellant provide information regarding the insured's medical condition pursuant to section 627.736(6)(b) in order to justify additional reimbursement.
The trial court disagreed with the appellant that USAA waived any defense because it paid medical reimbursement after filing suit, and determined that there was no statement of judgment. Ultimately, USAA did not wrongfully withhold payment."
EOR/EOB requests
The key issue raised in this case concerning the requirement to respond to emergency medical condition would be treated as a 627.736(6)( b) request states Florida statute 627.736(6)(b) :
(6) Discovery of facts regarding the injured person; Dispute.—
(b) Every physician, hospital, clinic, or other medical institution that, prior to the bodily injury or subsequently provides, on which a claim for personal injury protection insurance benefits is based, any products, services, or accommodation in respect of that or any other injury, or claimed to be related to that or any other injury In respect of the condition, if requested , against which the claim is made, the history, condition, treatment, dates and cost of such treatment of the injured person and items identified by the insurer as to why the claim is reasonable and medically necessary were, together with an affidavit stating that the treatment or services provided were reasonable and necessary in connection with the bodily injury and an identification of what part nor such treatment or expenses for services were incurred as a result of such bodily injury, and allow the inspection and transcript of his or her r's information regarding the history, condition, treatment, dates and costs of such treatment Record if it does not limit the introduction of evidence at trial.
What Florida Medical Providers Should Include in an Sworn Statement
Such sworn statement should read as follows: "Under penalty of perjury, I declare that I have read the foregoing, and the facts stated are true, To the best of my knowledge and belief."
A cause of action for infringement of physician-patient privilege or right to privacy may not be brought against any physician, hospital, clinic, or other medical institution complying with this section The person requesting such record and such affidavit shall pay all reasonable costs connected therewith.
If an insurer within 30 days of receiving notice of the amount of the loss covered under paragraph (4)(a) makes a written request for documentation or information under this paragraph within 10 days, the amount or part of the amount that is due to the insurer if the insurer does not pay in accordance with paragraph (4)(b) or 10 days , whichever is later the check is overdue.
As used in this paragraph, the term "receipt" includes, but including but not limited to inspection and copying in accordance with Article.
An insurer who requests documentation or information relating to the reasonableness of charges or medical necessity under this paragraph without a reasonable basis for such requests in the ordinary course of business practice shall be subject to the provisions of the Unfair Trade Practices Insurance Code of
Florida District Court (6 )(b) Interpretation of the statute The
court in this case qualified the condition by noting the words requesting an EMC determination of the " patient originally prescribed in 6b" in the plain language of this subsection as well as in the heading of the subsection Based on the above, it is clear that the focus of this provision is the discovery of documents in relation to the individual injured person's treatment and associated billing." State Farm v. Delray Med. Ctr., 178 so. 3d 511, 515 (Fla. 4th DCA 2015).
In the present case, USAA appropriately requested a report on the insured's medical condition. The report may likely affect USAA's evaluation of whether a qualified medical provider has determined that the insured's injury is an emergency medical condition.
As a result, the demand letter of the appellant was immature. Although Appellant filed a demand letter for payment of benefits, Appellant failed to respond to USAA's request for discovery pursuant to section 627.736(6)(b).
How does this affect Florida medical providers?
The determination in the above raises issues for medical providers. This case establishes that if you of Benefits or an Explanation of Review that states they are seeking patient status or EMC status, that serves as a (6)(b) request. Is.
You should respond to this request with an EMC determination or patient status. Not answering will do two things. 1) Your bill will not be treated as "overdue". 2) Dolman Law Group accident injury attorneys, PA cannot send demand letters to you.