Receiving Payment Under Fla. Statute (2009) - The PIP Statute

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1 got justice?

2 Receiving Payment Under Fla. Statute (2009) - The PIP Statute PIP pays 80% up to $10K of medical expenses as a result of bodily injury, sickness, disease, or death arising out of ownership, maintenance, or use of a motor vehicle. PIP pays 60% up to $10K of lost wages. PIP benefits shall be overdue if not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss...

3 What is written notice? HCFA/CMS form; Medical records; Disclosure and acknowledgment form ( D&A form). If such written notice is not furnished to the insurer as to the entire claim, any partial amount supported by written notice is overdue if not paid within 30 days after such written notice is furnished to the insurer.

4 Timely Filing of Claims- Required- Claims must be submitted within 35 days of the date(s) of service listed on the claim. The exception is that If the provider submits a notice of initiation of treatment within 21 days after the 1st exam or tx, then the provider has no more than 75 days from the postmarked date of the statement " to submit the claim to the insurer. If the insured does not furnish the provider with the correct name and address of their PIP insurer, the provider has 35 days from the date the provider obtains the correct information to submit the claim to the insurer.

5 Timing continued The provider must provide documentary evidence that was provided by the insured during the 35 day period demonstrating that the provider reasonably relied on erroneous information from the insured and either: a. A denial letter from the incorrect insurer; or b. Proof of mailing, which may include an affidavit under penalty of perjury, reflecting timely mailing to the incorrect address or insurer.

6 Timing continued What happens if you submit a claim, and the insurance company responds, that the claim was not timely filed? - Keep evidence in the client s chart/billing information of timely filing, such as: Proof of mailing: 1) Send the bills certified mail and keep hard copies of the current claim forms. 2) Mail ledger. 3) Copy of envelope. Establish a billing policy and procedure requiring bills to be submitted within 35 days of the date of service. Note the file or patient ledger as to the date when the bill was mailed out.

7 WHAT HAPPENS IF INS. CO. FAILS TO PAY CLAIM? - SEND A DEMAND LETTER IMMEDIATELY Pursuant to Florida Statute (10) the insurance company has 30 days to respond to the demand letter. Include in the demand letter: the claim number or policy number, patient name, assignment of benefits, name of provider, statement specifying the exact amount owed to date; including the date of service. Attach copies of HCFA/CMS form. Search for the insurance company s address with appropriate PIP Contact Name:

8 Failure to pay continued Go to: Type in the insurance company name, and use the PIP contact name and address. For IME cutoffs- include a proposed treatment plan. If benefits have exhausted, the insured is responsible for payment, and the insurer is not required to pay any more than the $10K available in benefits. If no payment is received, AND benefits remain, submit the claim to an attorney to file a PIP suit immediately. Time is of the essence!

9 DEMAND FOR PAYMENT PURSUANT TO (10), Fla. Stat. (2009) CERTIFIED MAIL, RETURN RECEIPT REQUESTED: GEICO Attn: George W. Rogers PO BOX 9091Macon, GA RE: Patient Name: (Assignment Attached) Claim Number: Dear Mr. Rogers: This is a demand letter under pursuant to Florida Statute (10) (2009). Enclosed are the itemized statements, for through dates of service. The amount at issue is $. Please remit payment in the amount of $. Under Fla. Stat , it is not mandatory that the aforementioned bills be paid pursuant to 200% of Medicare fee schedule. Please provide the undersigned with a PIP log immediately. If you have any questions about the bills at issue, please compare the attached ledger to your explanation of benefits and please note we dispute each and every reduction and nonpayment. If you still have questions or need additional documentation, please let us know. If you respond to this demand letter, we will assume this demand letter is acceptable. We are relying on you to tell us if this demand letter or this pre- suit notice is defective in any way before suit is filed. POSTAL COSTS REIMBURSEMENT IN THE AMOUNT OF $ & APPLICABLE PENALTY OF 10% AS PERMITTED BY FLORIDA LAW, IS HEREBY REQUESTED TO BE MADE PAYABLE TO:.

10 PAYMENT IN THE AMOUNT OF $ & STATUTORY INTEREST PERMITTED BY FLORIDA LAW IS HEREBY DEMANDED AND MADE PAYABLE TO:. Pursuant to Florida Statute and , and , respectively, a demand is hereby made for the following: 1) A copy of the policy, declarations page, and PIP payout log pursuant to Florida Statutes , (6)(d), and ) A copy of the explanation of benefits for each bill not paid or reduced; 3) A copy of any EUO, statement, or recorded transcripts; 4) A copy of all IME reports; 5) A copy of the letter(s) demanding the patient to appear at an IME, an EUO, or a telephonic recorded statement and proof of mail; and 6) A copy of any and all information obtained under the provisions of , as required by the provisions of (6)(d) Florida Statutes. You are hereby given notice that you must pay the amounts claimed, without reduction, under the terms of the applicable policy and , Fla. Stat. (2009), within thirty (30) days of receipt of this letter or we will file suit against you without further notice. Demand is made for the medical payments, postage, penalty and the interest to be paid to. All checks and documents are to be mailed to at the below referenced address within thirty (30) days. If you decline to make payment pursuant to this letter, please immediately reserve benefits at least equal to the disputed amount. Very truly yours,