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Don’t Let Insurance Companies Bully your Claims Target PIP and WC for Profits

Don’t Let Insurance Companies Bully your Claims Target PIP and WC for Profits. Brian F. LaBovick, President/CEO GO-SB. BASIC OUTLINE. Registration PIP – Personal Injury Protection WC – Workers Compensation Assignment of Benefits Bodily Injury Liens / Letters of Protections (LOP).

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Don’t Let Insurance Companies Bully your Claims Target PIP and WC for Profits

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  1. Don’t Let Insurance Companies Bully your ClaimsTarget PIP and WC for Profits Brian F. LaBovick, President/CEO GO-SB

  2. BASIC OUTLINE • Registration • PIP – Personal Injury Protection • WC – Workers Compensation • Assignment of Benefits • Bodily Injury Liens / Letters of Protections (LOP)

  3. 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.

  4. Sample Cards

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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

  11. 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.

  12. 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.

  13. EMTALAFederal 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.

  14. EMTALAHas 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.

  15. EMTALADefines 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…

  16. EMTALAAppears 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.

  17. Florida’sPIPLAW • 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…

  18. Florida’sPIPLAW • 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...

  19. Florida’sPIPLAW • 627.736 (5) CHARGES FOR TREATMENT OF INJURED PERSONS. 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…. In no event, however, may such a charge be in excess of the amount the person or institution customarily charges for like services or supplies. With respect to a determination of whether a charge for a particular service, treatment, or otherwise is reasonable, consideration may be given to evidence of usual and customary charges and payments accepted by the provider involved in the dispute, and reimbursement levels in the community and various federal and state medical fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service, treatment, or supply. • 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 charges. • 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. • d. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services. • e. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services. • 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, as determined under s. 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided. Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by the insurer. • 3. For purposes of subparagraph 2., the applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect at the time the services, supplies, or care was rendered and for the area in which such services were rendered, except that it may not be less than the allowable amount under the participating physicians schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B. • 4. Subparagraph 2. does not allow the insurer to apply any limitation on the number of treatments or other utilization limits that apply under Medicare or workers’ compensation. An insurer that applies the allowable payment limitations of subparagraph 2. must reimburse a provider who lawfully provided care or treatment under the scope of his or her license, regardless of whether such provider would be entitled to reimbursement under Medicare due to restrictions or limitations on the types or discipline of health care providers who may be reimbursed for particular procedures or procedure codes. • 5. If an insurer limits payment as authorized by subparagraph 2., the person providing such services, supplies, or care may not bill or attempt to collect from the insured any amount in excess of such limits, except for amounts that are not covered by the insured’s personal injury protection coverage due to the coinsurance amount or maximum policy limits.

  20. Florida’sPIPLAW • 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 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.

  21. Florida’sPIPLAW • 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).

  22. Florida’sPIPLAW • 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 …

  23. 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.

  24. 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.

  25. 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!

  26. 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.

  27. 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.

  28. 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.

  29. 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.

  30. Examples of Documents

  31. Examples of Documents

  32. Examples of Documents

  33. 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.

  34. Assignment of Benefit • Registration typically has a document that does a number of things: • 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)

  35. 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.

  36. AUTO-MATIC 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.

  37. AUTO-MATIC BI LIENS Lien ordinances, as allowed for by the state legislature. Alachua, Bay, Brevard, Bradford, Broward, Dade, Duval, Escambia, Hillsborough, Indian River, Jackson, Lake, Lee, Manatee, Marion, Monroe, Orange, Palm Beach, Sarasota, Seminole, and Volusia.

  38. 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)

  39. 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

  40. THE END Brian F. LaBovick, President/CEO GO-SB 5220 Hood Road, Suite 101 Palm Beach Gardens, Florida 33418 (561) 909-5559

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