The Changes to the Florida PIP law have worked to stop fraud: True or False?

The Changes to the Florida PIP law have worked to stop fraud:  True or False?

Dr. Alan Himmel

The articles are beginning to come out stating that the changes in the PIP laws that occurred in 2012 have decreased the rate of fraud, and costs to insurance companies, and ultimately to consumers.  This is a good thing if its true.  It may be that the decreases in payouts are due to the $2500 insurance cut off, or the 14 day rule, which states that you better get to a doctor within 14 days or you get $0.00 in coverage.  It may also be due to the fact that now, there is no coverage for acupuncture or massage, two effective, safe, alternatives to medications and surgery.

As a practitioner who sees accident patients in FL, doctors now have two less options to offer patients when they are suffering from painful injuries from automobile trauma.  Plus, patients have to get better with 75% less insurance coverage than they had in the past, since not all patients will have an "emergency medical condition"  (EMC) which is supposed to allow the patient to have their full benefit.

So, I ask you:  What do you think is the true reason that insurance companies are reporting savings?   Could the answer be that there is now more opportunity for the insurance carriers to deny coverage, since the payouts are capped now in many cases?  Or, could it be true that the savings is due to less fraud?   I would be one of the first to start celebrating if I was sure that the savings to insurance companies was about the reduction in crime, but I am not 100% sure about that one.

FL EMERGENCY MEDICAL CONDITION PIP DENIALS BEGIN

FL EMERGENCY MEDICAL CONDITION PIP DENIALS BEGIN

Dr. Alan Himmel

Just as predicted, there are some companies who are ignoring Emergency Medical Conditions and denying PIP coverage beyond $2500.   So, a medical provider, in many cases a specialist, will look at and examine a patient, and say, "Yes, without medical treatment, this patient is likely going to suffer long term permanent impairments,"  and write it exactly as the law is written, and certain insurance companies are having the doctor's notes and records reviewed by one of their doctors to say that its not true.

I just had a patient with an shoulder impingement syndrome denied.  The patient cannot raise her arm up past 90 degrees in any direction.  She cannot take a half gallon of milk out of the fridge due to pain and weakness in her shoulder, and an insurance company doctor says she needs no further treatment. The MRI alone was more than half her PIP benefit.

Surprisingly, this denial is happening with major providers.  You would think that the small rip-off companies would be doing this, but as I said, even the big boys are doing it.

So, what do you do?  As a doctor who spends a lot of time with patients one on one (sometimes more than an hour), I have to make a decision.  The decision is whether to release the patient from care, or to continue treating in the hopes that in the end, a suit can be filed, and the insurance company will eventually pay.  SInce this whole EMC thing is a new thing in Florida, there are a lot of unknowns.

The first unknown is whether a suit can be won in the first place.  Lawyers cannot guarantee a win. And, as I said, this is a new program in FL, so there is not a whole lot of new case law.   Secondly, if a suit is won, will the WHOLE bill be paid, or will only part of it be paid?  What if a Judge says, pay the bill, but only 20% of it?  Can they do that?  A colleague of mine seems to think so.  He may be right.

My patient with shoulder impingement I am continuing to see and treat.  She is doing better and better. Without treatment her condition would likely turn into frozen shoulder.