The New Florida PIP Statute How Are The Changes Impacting YOU? GO-SB Specialized Billing

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1 HFMA & AAHAM Nrth Bay Hspital Educatin Event The New Flrida PIP Statute Hw Are The Changes Impacting YOU? GO-SB Specialized Billing Mark Bibeau, CEO December 4 th, 2013

2 Agenda Histry f Flrida PIP Changes in the PIP Statute Prtecting Yur Payment Reimbursement Mdel Impact f Changes What Shuld Yu D? Infrmatinal Needs Speed Underpayments & Denials Current Legal Challenges

3 Histry Of Flrida PIP 1972 = 1 st t adpt N Fault aut insurance (nw there are 12 states with PIP) Why N Fault vs. Fault: Cverage fr all peple invlved in accidents and curtail lawsuits! N Fault Insurance Intended t reduce LAWSUITS! Cver all parties injured in an accident: medical, wages & burial $10,000 f cverage (PIP) Persnal Injury Prtectin COVERS THE INJURED NO MATTER WHO IS AT FAULT Other pssible insurance: (MED PAY) Medical Payments Insurance is nt cmpulsry & (BI) Bdily Injury Insurance The at fault party can als pay fr the medical bills. IN FLORIDA - Only PIP & Prperty Damage is mandatry!

4 Histry Of Flrida PIP (Cnt.) PIP is cnsidered a First Party Benefit (FPB) A prvider cannt lien PIP benefits Best Practice is t use an Assignment Of Benefits (AOB) t direct PIP benefits t the medical prvider PIP benefits are t be crdinated with a patient s health insurance upn the exhaustin f PIP benefits Dcumentatin required: PIP Exhaustin letter EOB with deductibles prperly applied PIP Denial Statute had numerus changes since 1972

5 Histry Of Flrida PIP (Cnt.) N Fault Prblems: Dctrs/Chirpractrs/Lawyers gamed the system. N Fault became expensive because f the fraud (Flrida is #1 in Fraudulent MVA claims) 40 Years later (2012) significant changes t the N Fault Statute were enacted t address these flaws Reign in escalating premium csts t cnsumers Reduce PIP fraud Reduce healthcare reimbursement amunts Cap legal fees assciated with PIP disputes QUESTION: Hw is yur hspital engaged in any f these negative activities? ANSWER: Yu aren t.

6 Histry Of Flrida PIP (Cnt.) Wh is cvered under PIP? Every persn in an aut crash shuld be cvered. Any injury via wnership, maintenance r use f a mtr vehicle Operatr, Passenger, Pedestrians Example: Seatbelt cuts hand f child N cverage if injury was self inflicted r received while cmmitting a felny r the peratr f a mtr cycle. What is the plicy pririty? 1. Patient s wn PIP (If yu wn a car yu must have PIP) 2. Resident Relative (T any degree by bld r marriage) 3. The Car yu are IN (if the abve desn t apply) 4. If a Pedestrian/Bicyclist use husehld PIP and if nne use the ffending car s PIP May need an affidavit fr #3 and/r #4.

7 NEW LAW - Changes in the Statute Medical treatment MUST be rendered within 14 days after the accident Must be prvided, supervised, rdered r prescribed by: Physician / Dentist / Chirpractic Physician / Hspital / Emergency Transprt / Hspital Owned Emergency Medical Clinic Fllw-up care MUST be rdered/referred by: A hspital r ambulatry surgical center A Physician (medical r stepath) Dentist Chirpractr Physician s Assistant Advanced registered nurse practitiner Physical therapist Certain health care clinics meeting the legal requirements

8 NEW LAW - Changes in the Statute Reimbursement fr Massage Therapy and Acupuncture was eliminated An injunctin allwing Message Therapy and Acupuncture t remain cvered was initially granted Recently the injunctin was lifted s n cverage PIP benefits reduced t $2,500 if nt an Emergency Medical Cnditin (EMC) Has already becme the mst cntested issue and we will discuss later. Wh can determine EMC? Physician (medical r stepath) r Physician s assistant Dentist Chirpractr Advanced registered nurse practitiner

9 BEST PRACTICE ADVICE Changes in the Statute Teach thse prviding ntes t avid subjective pinins in hspital s medical recrd(s) that culd be interpreted as giving a negative pinin n EMC Frce the Insurance C. t disprve it is EMC nt the ther way arund PIP benefits will remain at $10,000 if any f the abve (less Chirpractr pinins) treats the cnditin as if it were an EMC

10 NEW LAW - Changes in the Statute Emergency Medical Cnditin HB 119 defines EMC as a medical cnditin manifesting itself by acute symptms f sufficient severity, which may include severe pain, such that the absence f immediate medical attentin culd reasnably be expected t result in any f the fllwing: Serius jepardy t patient health Serius impairment t bdily functins Serius dysfunctin f any bdily rgan r part Hspitals shuld cntinue t d exactly what they have been ding fr years until further advised Extremely rare t read a nte that indicates that the patient did nt require medical treatment

11 ANTI FRAUD PROVISIONS NEW LAW - Changes in the Statute Insurers can cmpel an examinatin under ath (EUO) Insurer can frce an Independent Medical Exam (IME) If patient fails t appear 2x insurer can refuse t pay bills The pinin f an IME Dr. shuld nt be cnsidered as a medical prvider entitled t determine EMC (lack f impartiality) Insurer can require that prviders furnish a written reprt f the histry, cnditin, treatment dates and csts f the services rendered tgether with a swrn statement that the services were reasnable in amunt and medically necessary Attested/certified cpies f the hspital s itemized bill and medical recrds will typically satisfy this request

12 NEW LAW - Changes in the Statute Billing Requirements Prviders use UB-04 and/r 1500 May need t supply additinal billing details Shuld prvide the medical recrds as speed matters Insurers are required t keep a PIP lg f bills submitted Payment is t be made n first in - first ut mdel unless a bill is questined and requires additinal dcumentatin

13 Changes in the Statute BEST PRACTICE Get Bill ut FAST! Submissin f a hspital based claim shuld be within 7 days. Yu culd take 35 days frm the date f service but that risks the maximizatin f benefits. The 35 day time frame in the PIP Statute is nt mandatry fr Hspitals. It is mandatry fr ther prviders. Withut quick submissins the PIP may/will exhaust If a dctr/prvider lacks PIP Infrmatin, they shall have 35 days t bill the PIP frm the date the PIP infrmatin was prcured. Getting the Investigatin n PIP and which PIP Plicy Applies (The Sherlck Hlmes wrk in the Billing Dept. is imperative) Best Practice Advice: Train Intake Staff n PIP laws s they knw the right questins t ask and hw imprtant it is t get that inf.

14 Prtecting Yur Payment Secure PIP infrmatin ASAP Submit a clean claim with supprting dcumentatin Nn-hspital Medical Prviders must be familiar with and submit a PIP Initial Treatment Frm when required Knw when yu can and can t balance bill the patient: Yu can NOT balance bill if the payments were made t the full extent prvided n the fee reimbursement calculatin Yu CAN balance bill fr: Patient C-Insurance Amunts & Amunts abve the PIP Exhaustin Up-cding and unbundling f charges is prhibited The insurer may nt apply treatment r ther UR limits when cnsidering payment

15 Reimbursement Mdel Insurers may limit reimbursement t 80% f the apprved maximum charges: A. Emergency services: 75% f usual and custmary which is typically grss charges) x 80% ($1000 x 75% x 80% = $600) Deductibles are subtracted frm grss charges B. Inpatient services: 200% f Medicare Part A Prspective Payment Schedule times 80% C. Outpatient services: 200% f Medicare Part A Ambulatry Payment Classificatin times 80% D. Supplies: 200% Medicare Part B fee schedule times 80% E. If nt listed abve: 80% f maximum reimbursable allwance in Flrida Wrker s Cmpensatin Fee Schedule PIP is bifurcated fr the first 30 days (50% fr dctrs and 50% fr Hspitals/Facilities)

16 Reimbursement Mdel Cnt. Insurers have 30 days t issue payment If late simple interest and a small penalty is als due If Insurer pays nly PART f the bill r CLAIMS a billing errr: Prvider has 15 days t submit a revised claim fixing the issues in the EOB Insurer can deny fr the fllwing reasns: Treatment was unrelated t accident Services were nt medically necessary r unreasnable Amunt charged exceeded allwed amunt The claim was wrk related PIP is primary EXCEPT if the injury r illness is wrk related Underscres imprtance f registratin securing as much infrmatin as pssible

17 Impact f Changes Benefits pssibly reduced frm $10,000 t $2,500 Sme claims may be denied fr late submissin Increased paperwrk and dcumentatin Delays in reimbursement due t investigatins Denied payments because patient failed t attend IME Errneus reimbursements Insurers are nt prepared t prperly calculate the new rates Insurers will apply the wrng fee schedule t their calculatin Insurer may apply the wrng mdel year t their calculatins nt prperly based n the patient s plicy renewal dates Insurer may nt pay pursuant t their plicy requirements.

18 What Shuld Yu D On Yur DAY ONE BILLING Secure the infrmatin yu need t get yur bill ut the dr fast. (Registratin training is a must) Make every effrt t prepare and submit yur PIP billing package within 3-7 days. Watch ut fr back dr r Silent PPOs. Althugh frequently binding sme are nt AND prviders shuld cnsider carving ut MVA and WC when renegtiating. Bill as quickly as yu can and fllw up aggressively. It is a race and the prize is cash!

19 HOW TO DEAL WITH Underpayments & Denials Great Opprtunity fr Quick Mney n Zer Balance Claims! Prvider may resubmit a crrected claim within 15 days frm receipt f Insurer s EOB indicating partial r denied payment due t an errr Failure t resubmit des nt stp the prvider frm enfrcing their legal rights, which is t file a lawsuit. (Unnecessary with right Rep) Written ntice f the prviders intent t sue is required prir t the filing f an actin (Must cmply with statutry requirements r it will be rejected and n additinal funds tendered) Must identify itself as a Demand Letter Must include the name f the insured Must include a cpy f the AOB Must have the Claim r Plicy Number Must have the Name f the prvider, an itemized statement f charges, the date f treatment and the type f benefits which are due.

20 The Demand: GETTING PAID ON Underpayments & Denials Must be certified/registered mail - return receipt requested T the Address designated fr the insurer n file G t: t find the right address. Beware! Insurers change their PIP demand address frequently Insurer has 30 days t cure. Cure must include small Penalty & Interest If paid timely the prviders right t sue is extinguished If nt paid prvider may seek further legal remedies Cntinued abuses can subject insurer t penalties under State s Bad Faith Laws and Unfair & Deceptive Trade Practices Act.

21 Current Legal Challenges Definitin f Emergency Medical Cnditin and the applicatin f the $2, cap 14 Day time requirement fr initial treatment Interpretatin f Reimbursement Mdels Silent PPO disputes (was the insurer a member f the PPO prir t the rendering f the services t the patient?) Which mdel and fee schedule t apply (pre 2013 r pst) Timely filing deadlines Applicatin f deductibles given the Medicare based reimbursement structure

22 Thank Yu! Mark Bibeau, CEO (877) 358-GOSB (4672) C: (978) Renee Burger, Directr, Sales & Marketing (904) GO-SB Specialized Billing 9000 Burma Rad, Suite 103 Palm Beach Gardens, FL 33403