Don’t Let Insurance Companies
Bully your Claims
Target PIP and WC for Profits
Brian F. LaBovick, President/CEO GO-SB
BASIC OUTLINE
1.
2.
3.
4.
5.
Registration
PIP – Personal Injury Protection
WC – Workers Compensation
Assignment of Benefits
Bodily Injury Liens / Letters of
Protections (LOP)
Registration
• Registration must collect information so Billing can do their job.
• Maximize revenue on 3rd Party Liability insurers by getting good information
• Train to probe intakes with NON-LEADING QUESTIONS
• Registration is the best opportunity to get whatever you want. The Patient
or their representative will do whatever is necessary to get the medical help
they need.
• Get copies - Driver’s Licenses, Resident Alien Cards, Passports, Automobile
Insurance, Social Security Card, any Worker’s Compensation information.
• Copy the Health Insurance Card, Medicare Card, Medicaid Card and/or
Veteran's Identification Card (VIC) regardless. You will need the info later.
Sample Cards
Target - PIP
• FSA Section 627.736 sets out all the
required personal injury protection benefits;
exclusions; priority; claims
• PIP Pays for reasonable medical bills and
lost wages and even death benefits.
• The medical bill reimbursement use to be
80% of reasonable and customary.
• Now the statute breaks up inpatient,
outpatient, emergency care from the
hospital and emergent care with the doctor.
To collect PIP You need to know…
Do you own a car? IF YES – This is your Primary Insurance
Was your car the car which was involved in the accident?
– If the person owns a car they must, under the law, have PIP
insurance on the car and that insurance is primary.
– If they do not have PIP you will need to bill health or it is a
self pay account and that means no money is going to the
hospital.
What if they DO NOT OWN a car?
• RESIDENT RELATIVE - Do you live with anyone who owns a car?
• Is that person your relative? If they live with any relative, of any degree, blood or
marriage, then that person’s PIP is on the hook for your hospital bill.
• If the person is a cousin ask HOW are they your cousin? Mother/Father etc. Within
the Latin culture I have experienced people who believe they can only live with their
relatives, so they all say they are cousins when they are not.
• If they are related you need the relative’s automobile insurance information. You
may need to investigate that person.
• IN THE CAR: If they do not live with a relative you need to know if were in a car at
the time of the accident. If they were then they get that car’s PIP insurance.
• DEFENDANT’S PIP: If the Patient was not in a car but was a pedestrian or bicyclist,
you will be able to go after the DEFENDANT’S PIP insurance. You will need the name,
number, etc. The Patient will not recall that, but they may have an Exchange of
Information form, so it may have that parties name on it.
• PIP is NO FAULT – That means the claim against the other driver is appropriate
regardless of fault.
What if they DO NOT LIVE with a
Resident Relative?
• USE THE PIP OF THE CAR IN THE ACCIDENT: If they do not live with a relative you
will need to determine who owned the car they were in at the time of the accident.
• If they were in or around that car when they were hurt, then they get that car’s PIP
insurance.
• If they were not in a car: Pedestrian and most likely a bicyclist, you will be able to
go after the DEFENDANT’S PIP insurance. That is the only time you will be able to
directly bill the other party’s insurance. That means you need their name, number,
etc. The Patient will not likely recall that, but they may have an Exchange of
Information form, so it may have that parties name on it.
• PIP is NO FAULT – That means the claim against the other driver is appropriate
regardless of fault.
What if they WERE NOT IN A CAR?
• If they were NOT in a car then the Pedestrian rules apply. The same is true for a
bicyclist. You will be entitled to ask for the OTHER PARTY in the accident’s PIP
insurance.
• That is the only time you will be able to directly bill the other party’s insurance.
That means you need their name, basic information, driver’s license number, etc. The
Patient will not likely have any of that information so ask for an Exchange of
Information form. Or ask the officer when she comes to visit the Patient.
• REMEMBER: PIP is NO FAULT – That means the claim against the other driver is
appropriate regardless of fault.
Who is Primary PIP vs. Work Comp.
• Common practice and belief is that Workers Compensation is PRIMARY.
• It is unfortunately true.
• However, there are a large number of providers who bill PIP anyway. Guess what:
PIP Pays without question.
• 627.736(4) BENEFITS; WHEN DUE.--Benefits due from an insurer under ss.
627.730-627.7405 shall be primary, except that benefits received under any workers'
compensation law shall be credited against the benefits provided by subsection (1)
and shall be due and payable as loss accrues, upon receipt of reasonable proof of such
loss and the amount of expenses and loss incurred which are covered by the policy
issued under ss. 627.730-627.7405
PIP - Days to File Claim and
Time to Demand Payment.
• Under the PIP Statute the Hospital has the first $5000 in PIP benefits set aside to
help cover their bills. This benefit is open for 60 days.
• Why wait? Injury cases are attacked by Chiropractors and Pain Clinics as well as
Orthos and Neuros. You need to get your hospital claim in first and fast!
• 627.736(4)(c) Upon receiving notice of an accident that is potentially covered by
personal injury protection benefits, the insurer must reserve $5,000 of personal injury
protection benefits for payment to physicians… or dentists … who provide emergency
services and care, as defined in s. 395.002(9), or who provide hospital inpatient care….
After the 30-day period, any amount of the reserve for which the insurer has not
received notice of a claim from a physician or dentist who provided emergency
services and care or who provided hospital inpatient care may then be used by the
insurer to pay other claims.
PIP Reimbursement Rates
• 627.736(5) CHARGES FOR TREATMENT OF INJURED PERSONS.-• 2. The insurer may limit reimbursement to 80 percent of the
following schedule of maximum charges:
• a. For emergency transport and treatment by providers licensed
under chapter 401, 200 percent of Medicare.
• b. For emergency services and care provided by a hospital licensed
under chapter 395, 75 percent of the hospital's usual and customary.
• c. For emergency services and care as defined by s. 395.002(9)
provided in a facility licensed under chapter 395 rendered by a
physician or dentist, and related hospital inpatient services rendered
by a physician or dentist, the usual and customary charges in the
community.
EMTALA
Federal Emergency Medical Treatment and Labor Act
42 USC 1395dd, part of the U.S. Code
Medical screening requirement
Any hospital with an ER department… must
provide an appropriate medical screening
examination, including ancillary services, to
determine if an emergency medical condition
(within the meaning of subsection (e)(1) of this
section) exists.
EMTALA
Has Teeth
ENFORCEMENT
Civil money penalties - A participating hospital that negligently violates a requirement
of this section is subject to a civil money penalty of not more than $50,000 (or not
more than $25,000 for a hospital with less than 100 beds) for each violation.
Civil enforcement - Any individual who suffers personal harm as a direct result of a
participating hospital’s violation of a requirement of this section may, in a civil
action sue that hospital in a personal injury case, under the law of your State, and
such equitable relief as is appropriate.
Financial loss to other medical facility - Any medical facility that suffers a financial
loss as a direct result of a participating hospital’s violation of a requirement of this
section may, in a civil action against the participating hospital, obtain those
damages available for financial loss, under the law of the State in which the
hospital is located, and such equitable relief as is appropriate.
EMTALA
Defines the terms
(e) Definitions
(1) The term “emergency medical condition” means— a
medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that the
absence of immediate medical attention could reasonably
be expected to result in—
(i) placing the health of the individual in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part…
EMTALA
Appears to coordinate with PIP Terms
EMTALA does a great job defining the key terms as they apply to the PIP statute
'emergency medical condition' and 'medical screening‘ etc.
EMTALA also helps explain why the PIP statute says emergency services and care
provided by a physician and those services in furtherance of a physicians orders
etc...and those services which are provided to relieve the emergency medical
condition Must be paid at 80 percent of the bill and not 75/80. This is obviously
because this type of language and standard is used often around the hospital.
Florida’s
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• 627.736 Required personal injury
protection benefits
Every (Auto) insurance policy… shall provide
personal injury protection to the named
insured, relatives residing in the same
household, persons operating the insured
motor vehicle, passengers in such motor
vehicle, and other persons struck by such
motor vehicle and suffering bodily injury
while not an occupant of a self-propelled
vehicle… to a limit of $10,000 for loss
sustained by any such person as a result of
bodily injury, sickness, disease, or death
arising out of the ownership, maintenance,
or use of a motor vehicle…
Florida’s
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• 627.736 Required personal
injury protection benefits
(a) Medical benefits.--Eighty
percent of all reasonable
expenses for necessary medical,
surgical, X-ray, dental, and
rehabilitative services, including
prosthetic devices, and
necessary ambulance, hospital,
and nursing services...
Florida’s
• 627.736 (5) CHARGES FOR TREATMENT OF
INJURED PERSONS.
P
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Any physician, hospital, clinic… rendering
treatment to an injured person for a
bodily injury covered by PIP may charge
the insurer and injured party only a
reasonable amount pursuant to this
section for the services and supplies
rendered, and the insurer providing
such coverage may pay for such
charges directly to such person or
institution….
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Florida’s • 627.736 (5) CHARGES FOR TREATMENT OF
INJURED PERSONS.
P
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2- The insurer may limit reimbursement to 80
percent of the following schedule of
maximum charges:
a. For emergency transport and treatment
200 percent of Medicare…
b. For emergency services and care provided
by a hospital 75 percent…
c. For emergency services and
care…rendered by a physician or dentist…
the usual and customary charges in the
community.
Florida’s
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• 627.736 (5) CHARGES FOR TREATMENT
OF INJURED PERSONS.
• d. For hospital inpatient services,
other than emergency services and
care, 200 percent of the Medicare
Part A…
• e. For hospital outpatient services,
other than emergency services and
care, 200 percent of the Medicare
Part A Ambulatory Payment
Classification... (individual per your
hospital).
Florida’s
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• 627.736 (5) CHARGES FOR TREATMENT OF
INJURED PERSONS.
• f. For all other medical services,
supplies, and care, 200 percent of the
allowable amount under the
participating physicians schedule of
Medicare Part B. However, if such
services, supplies, or care is not
reimbursable under Medicare Part B,
the insurer may limit reimbursement to
80 percent of the maximum
reimbursable allowance under workers’
compensation… FS. 440.13 …
WHAT TO DO WHEN PIP DOESN’T PAY
627.736(10) PRIOR TO FILING A LAWSUIT FOR PIP BENEFITS THE
PROVIDER (HOSPITAL) MUST FILE A NOTICE OF INTENT TO INITIATE
LITIGATION (a DEMAND)
• The DEMAND must not be sent until the claim is overdue.
• The DEMAND must say it is a “Demand letter under Florida
Statute 627.736(10).”
• The DEMAND must include the name of the insured.
• Include a copy of the Assignment Of Benefits which gives
rights to the hospital to bring the claim.
• The original claim number or policy number used by the
insurer to identify the claim.
PIP DEMAND LETTER INFO CONT…
• The NAME of the medical provider who rendered to an
insured the treatment.
• An Itemized Statement specifying the exact amount, date,
service, or accommodation, and the type of benefit claimed to
be due.
• The notice must be delivered by US certified or registered
mail, return receipt requested. (Postal costs shall be
reimbursed by the insurer if requested.)
• Make these letter tough. There is no bad PR with your clients.
There is no bad PR with the Carriers. They are designed to
deny your full payment on every single transaction.
WHAT NEXT - PIP DEMANDS CONT…
If the PIP Insurance Co. pays the DEMAND within 30 days after
receipt of a NOTICE by the insurer, the overdue claim as specified in
the notice is paid by the insurer together with applicable interest and
a penalty of 10 percent of the overdue amount paid by the insurer,
subject to a maximum penalty of $250, no action may be brought
against the insurer.
The Statute of Limitation for an action under this section is tolled for
a period of 30 business days by the mailing of the notice required by
this subsection.
• DO NOT WAIT – You must get these Demand letters in fast.
• IF THEY DENY THE DEMANDS THEN YOU ARE PERMITTED TO SUE.
ATTORNEYS DO THIS ON A FULL NO RISK CONTINGENCY FEE!
Target – Worker’s Compensation
• Florida Statute: Section 440.13 Medical services and supplies;
penalty for violations; limitations.
• http://www.myfloridacfo.com/wc/pdf/2006HOSP.pdf
FLORIDA WORKERS' COMPENSATION REIMBURSEMENT MANUAL FOR HOSPITALS
• BEWARE of the PATIENT: At registration ask if the person was on
the job when injured.
• Many people try and avoid bringing in Workers Comp.
• People do not want their employer on the hook for their own
clumsy mistakes. They want to make sure their employer knows
they are a loyal employee.
• You have the obligation of knowing about WC and gathering that
documentation.
• That is not easy but can be done. Ask for their business card at
registration. As a matter of form you need to always get the
business card.
WC Reimbursement Rates
A hospital shall obtain authorization from the insurer prior to
providing any non-emergency medical treatment, care or
attendance for a patient’s work-related injury or condition.
Emergency services and care, defined in s. 395.002, F.S., do not
require authorization when services are rendered. However, the
hospital shall notify the insurer by telephone within 24 hours of the
admission, as required by s. 440.13(3)(b), F.S.
When it is determined that an emergency medical condition does
not exist or no longer exists and only non-emergent follow-up
examination or services are required or recommended, any related
follow-up care or treatment or referral must be expressly
authorized by the carrier prior to the provision of the additional
treatment or care pursuant to s. 440.13(3) (c), F. S.
WC Appeals
• 440.13(7) UTILIZATION AND REIMBURSEMENT DISPUTES.-• (a) Any health care provider, carrier, or employer who elects to
contest the disallowance or adjustment of payment by a carrier
under subsection (6) must, within 30 days after receipt of notice
of disallowance or adjustment of payment, petition the
department to resolve the dispute.
• The petitioner must serve a copy of the petition on the carrier
and on all affected parties by certified mail.
• The petition must be accompanied by all documents and records
that support the allegations contained in the petition.
• Failure of a petitioner to submit such documentation to the
department results in dismissal of the petition.
WC Appeals
• 440.13(7) UTILIZATION AND REIMBURSEMENT DISPUTES.
• If the Hospital properly submits a Petition to contest the Worker
Comp Ins. Carrier’s disallowance or adjustment and that Petition
does NOT contain all the information necessary to allow the
Carrier to determine the claim, the Carrier will file a Notice of
Deficiency
• The Notice of Deficiency is DANGEROUS. The Hospital only has
10 days to respond to this Notice. It is supposed to detail for
the Hospital the necessary curative records, documents and
other information necessary to properly pay the claim.
• It may also include a Notice of Rights explaining the hospital’s
rights, but that Notice is not required.
Examples of Documents
Examples of Documents
Examples of Documents
WC Appeals
• 440.13(7) UTILIZATION AND REIMBURSEMENT DISPUTES.-• (c) Within 60 days after receipt of all documentation, the
department must provide to the petitioner, the carrier, and the
affected parties a written determination of whether the carrier
properly adjusted or disallowed payment.
• The department must be guided by standards and policies set
forth in this chapter, including all applicable reimbursement
schedules, practice parameters, and protocols of treatment, in
rendering its determination.
• There is NO WAY to enforce this. The Dept. can take as long as
they want unless you want to Petition for Habeas Corpus which
is a waste of time.
Assignment of Benefit
• Registration typically has a document that does a number of
things:
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Consent to Medical Care
Release of Liability for Independent Contracted Doctors
Authorization to Disclose Health Information to Family and Doctor
SSN Release for Records of Permanent Hardware tracking
Responsibility for Valuables and Personal Belongings
Statement to Permit Payment of Medicare Benefits Part A & B
Agreement to be billed by Specialists and other Independent doctors
THE MOST IMPORTANT DOCUMENT IS…
• Assignment of benefits: An arrangement by which a patient requests
that their health benefit payments be made directly to a designated
person or facility, such as a physician or hospital. (www.dictionary.com)
• Do not put into your Assignment Drop Dead Dates (ala Florida Hospital)
Bodily Injury Liens (BI)
• BI commonly refers to the insurance that pays for a persons
bodily injury in an accident.
• Many Providers/Hospitals know these documents as Letters of
Protection (LOP).
• The LOP is a contract between the Patient and the Doctor or
Hospital.
• The LOP is the Patient’s Promise to Pay the medical bill at the
end of the injury case.
• Why doesn’t the Hospital obtain an LOP in every case? You
can have the patient sign a contact right up front.
• Your Hospital has the right to collect on that Personal Injury
Settlement. You can make that happen.
AUTOMATIC
BI
LIENS
• The Automatic Lien counties permit “public”
or “charitable” hospitals (also called
“qualified” hospitals) to have an automatic
lien on the patient’s third party settlement .
• Under Florida's Hospital Lien Act, in these
counties, a lien attaches from the moment
an injured person receives services in a
qualified hospital.
• The lien, attaches to all suits and claims, and
upon all judgments and settlements
resulting from the illness or injury which was
the reason for hospital care. The lien is not a
lien against the patient, but rather, against
all third-party payers.
Lien ordinances, as allowed for
by the state legislature.
Alachua, Bay, Brevard, Bradford,
AUTO- Broward, Dade, Duval, Escambia,
MATIC
Hillsborough, Indian River,
BI
Jackson, Lake, Lee, Manatee,
LIENS
Marion, Monroe, Orange,
Palm Beach, Sarasota,
Seminole, and Volusia.
AUTOMATIC BI LIENS
• ATTORNEY FEES SUPPLANTED:
– The Dade Ordinance goes so far as to
supplant the Patient’s attorney’s fee!
– See Crowder v. Dade County, 415 So. 2d
732 (3rd DCA 1982) and
– Public Health Trust of Dade County v.
O'Neal, 348 So. 2d 377 (3rd DCA 1977)
AUTOMATIC BI LIENS
• A hospital's lien takes priority over:
• Personal injury protection benefits
(P.I.P.) including funeral expenses and
lost wages.
• A hospital lien can be intended to be
effective for the "full amount" against
the proceeds of a judgment or
settlement in favor of the patient
(hospital), and is not to be diminished
by the amount of any attorneys' fees
THE END
Brian F. LaBovick, President/CEO GO-SB
5220 Hood Road, Suite 101
Palm Beach Gardens, Florida 33418
(561) 909-5559