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.

Emergency Chiropractic Florida

Emergency Chiropractic Florida

Dr. Alan Himmel

I decided to create another website:   www.emergency-chiropractor-florida.com

I named it Emergency Chiropractic of Florida because I continue to see patients who have been to the hospital or other doctor after a car accident, and it has been determined that they have an "emergency medical condition."  The designation of emergency medical condition or (EMC) allows the patient to seek follow up care and be covered by his PIP insurance up to his full coverage limits. Without the EMC, he is limited to only 25% of the coverage he pays for.  Not all of my car accident patients actually do have a bonafide EMC, and as a matter of fact, the EMC is only present if certain medical providers such as an MD or DO say it is present.

Nevertheless, these emergency patients often end up calling me because of my experience and my knowledge in regard to the proper treatment, management, and documentation of these types of injuries.  This comes with practically 18 years experience.  If you have been injured in a car accident, please call my office.  The number is 954-659-8600.

Dr. Alan Himmel

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.

Florida PIP EMERGENCY MEDICAL CONDITION (EMC) Form

EMERGENCY MEDICAL CONDITION (EMC)

Dr. Alan Himmel @ MiramarChiropractor.com

For those physicians providing care to Florida patients involved in automobile accidents, this is important information:

THERE IS NO SPECIAL EMC FORM.

1.  The new law states that if the MD, DO, PA, Nurse, or dentist does not notate the patient file that the injured patient has an "emergency medical condition", the patient is limited to only $2500 of the full $10k in PIP insurance that the patient paid for.  

2.  This means that if in the future, the patient requires further medical care including diagnostic imaging, or surgical procedures, the patient will likely be cut off at $2500 from medical care.

3.  There is no rule that says that the EMC must be completed within 14 days.  Only that the first visit to a doctor must be within 14 days.  So, as long as the patient was initially seen within 14 days of his accident, he is covered under his FL PIP coverage.  

4.  If you see the patient and the patient comes in (up to 5 years) post accident beginning Jan 1, 2013, you should still designate the EMC (if the patient's condition warrants it)  in the patient file or you will most likely NOT get your bill paid.

5.  There is no special form for the EMC.  Just document it in the patient's file.  Just write, "medical emergency"  if the patient's condition warrants it.  It is recommended that you state that your decision to write that the patient has an EMC agrees with  one or more of these below:

(a) Serious Jeopardy to the patient health.
(b) Serious impairment to bodily functions.
(c) Serious dysfunction of any bodily organ or part.

6.  I am not a lawyer, so my disclaimer to you is that you should contact a PIP litigation lawyer in the state of Florida regarding any legal matter including this one.  

Florida PIP No-Fault Blog--This Weeks Search Queries.

Top Search queries which brought people to the Florida PIP No-Fault Blog.

Dr. Alan Himmel

June 13, 2013.  

Q:  Can an 18 year old get only PIP insurance?
A:  No.  The minimum coverage in the State of Florida is PIP and PD.  Everyone must have at least personal injury protection and property damage liability coverage.  

Q:  "EMC doctors in Pembroke Pines Florida"
A:  Right now, the way it stands, the EMC diagnosis may not be needed.  There has been a temporary injunction to parts of the no-fault law.  However, many attorneys are still recommending patients see an MD if there is a need for documenting an emergency medical condition.  The problem is that some insurance companies may try to enforce the EMC rule, and without it, the patient is left with only 1/4 the coverage that was paid for.  To be sure, however, if I were you, I would ask an attorney.  

Q:  "Car accident 14 day treatment"
A:  This person probably wasn't sure, but he heard that PIP treatment must commence by 14 days of an accident.  Correct!  You have 14 days to begin care.  If you went to the hospital, this counts.  Also, your family doctor, chiropractor.  This is one part of the no-fault law that was not contested.  It still stands.

Q:  "Florida EMC form for accidents"
A:  The Florida Department of Financial Services or any insurance company as far as I know have NOT created an EMC form.  I have googled it for months now, and not once have I seen a standard form for the EMC.  Remember, also, the EMC requirement is likely ON HOLD for the time being.  You should check with your attorney on this.

Q:  "Car accident Florida Massage therapy pain"
A:  If you are wondering if massage is covered under PIP, yes, the temporary injunction to the new PIP law is allowing massage like it always has.  However, some lawyers still recommend staying away from massage since there will be a few insurance companies that will try to deny medical claims for massage services.

Q:  "Will PIP pay my medical bills after IME" 
A:  IME stands for independent Medical Exam.  Insurance companies will send claimants to a doctor to get a second opinion.  This almost always means that the patient's coverage will be terminated after the exam, because the IME doctor almost always states that the patient can no longer benefit from care.  I have never let this exam limit my patient's access to treatment if the patient and I think it's needed.  The insurance company will usually send out a letter to the patient which states there is no more coverage, and this very often dissuades the patient from continuing even if they truly need the care.  They are afraid of being stuck with a bill they cannot pay.  Come see me at my office.  954-659-8600 Dr. Himmel

If your benefits are terminated by your insurance company, I have been very successful in getting the treatments paid for anyway.  Just call me.  I will see what I can do.