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.

Emergency Medical Condition: A Gaping Hole In The New Florida PIP NO-FAULT Bill, HB119

A GAPING HOLE IN THE EMERGENCY MEDICAL CONDITION AS IT IS WRITTEN IN HB119, FLORIDA PIP NO-FAULT LAW.

The following excerpt is DIRECTLY from Florida HB119, the 2012 FLORIDA PIP Legislation.

So, how do you interpret this statement, directly from the bill, lines 750-754?


750 4.  Reimbursement for services and care provided in 
751 subparagraph 1. or subparagraph 2. is limited to $2,500 if any 
752 provider listed in subparagraph 1. or subparagraph 2. determines 
753 that the injured person did not have an emergency medical 
754 condition.


Here is the link to the whole bill.  Its a PDF:
http://flsenate.gov/Session/Bill/2012/0119/BillText/er/PDF


Read the excerpt, and read it again.

Its states that the benefits are limited to $2500 if an [MD, DO, PA, ARNP] determines it is NOT an emergency medical condition.

So, I ask you to read it again.  I am not going to try and explain it, since I am not a lawyer.

But, it seems that according to this statement, there must be a doctor who states it is NOT an EMC, otherwise the coverage defaults to the original $10,000.



Do you see this?  This doesn't seem to be what the insurance companies intended, but it looks like when you get a bunch of politicians who haphazardly write a bill to get it through, there could be some mistakes, and this seems like a big one.  Do you think they will "revisit" the subject during this year's legislation?  Possibly.  There have already been some word that they want to tweak the bill to possibly tighten it up a bit.  They cannot have holes in the bill like this.  If you are running an auto insurance company, this is not good, and you are not happy.

So, any opinions on this?

Dr.Alan Himmel
954-659-8600

FL PIP "EMERGENCY MEDICAL CONDITION" (EMC) FORM

FLORIDA PIP "EMERGENCY MEDICAL CONDITION" (EMC) FORM

Dr. Alan Himmel

If you are looking for a Florida PIP medical condition form, there isn't one.




At least, not yet.

 As of today, which actually is Jan 15, 2013, (the deadline if you had your accident on Jan 1 and have not seen a doctor yet), the Florida department of insurance or the department of financial services have not issued a standard form.  Also, they have not even recommended to the insurance carriers that there should be a standard form.  Therefore, if you are a doctor who treats auto injury trauma patients, you wouldn't have any idea where to make the statement of an emergency medical condition or not.  Common sense would say that there should be a standard form or something should be written in the notes.  I had one insurance adjuster for Allstate tell me that it should be put on the claim form.  When I asked him where, he told me he did not know.  There are no extra boxes to designate emergency on a HCFA 1500 form, and there certainly are no extra boxes to write in how the injury fits the EMC definition as we have been reading it.  You can put in your diagnosis codes there, but that's all.

Hypothetically, it would be more realistic for the doctor to write in his chart note something like:

"I have examined this patient and have given the diagnosis of "brain concussion", with the symptoms of loss of balance, inability to concentrate, nausea, severe headache, etc., and have determined that this condition may cause serious jeopardy to the patient's health.  Thus, this patient has a severe injury which is an emergency medical condition."



This is probably the best bet at this point since there has been no instruction to the doctors about how this should be done.

Of course, any insurance company can tell you that your "emergency medical condition" is not severe enough.  Those insurance companies will disregard your doctor's EMC and limit you to 25% of the coverage you paid for, but that's another story.

This is only my opinion, and not advice.    I hope it helps.

Pembroke Pines Chiropractic
954-659-8600
305-979-5549

Soft Tissue Injuries: Whiplash Recovery is Estimated to be at 50% or less.

Soft Tissue Injuries.  Whiplash Recovery is Estimated to be at 50% or less.

Alan Himmel, DC.,PA.

I wanted to talk for just a little bit about soft tissue injuries.

Most people think that unless you are a person who has suffered from a soft tissue injury (STI), that these types of injuries are no big deal. Well, nothing can be further from the truth, and I'll tell you why:

The body is an amazing thing. If you simply step out of the way, and let the body do what it does, it heals itself pretty well. For example, of you cut your finger, bite your lip, or even sustain a burn, the skin goes through a process of healing where it sends some specific blood cells to the scene of the injury and gets the job done. Even bone heals up pretty nice as long as the fracture doesn't involve a joint or articulation between two bones.

But, an injury to muscle, ligament, or tendon, or nerve is not the same as a small scratch or a bruise.  I mean, the cellular and chemical process by which the body begins the healing process is the same, but since the injury affects muscles, ligaments, tendons, and nerves, the injury will generally affect the ability of the person to move their body and function.



Anyone who has ever sprained an ankle or a knee knows that these injuries, despite the body's best attempt at healing, take a very long time and also cause permanent deficits in function. Injured tendons and ligaments and other soft tissue usually involves fine tears of the fibers. There are of course different grades of these types of injuries which range from a few small torn micro-fibers, to a severe tear or rupture which should be surgically repaired to reconnect. Every sprain, whether it happens to a person's neck as in a whiplash, or ankle while playing basketball, involve torn fibers. These pulled and torn  fibers are the cause of pain, inflammation and loss of range of motion which is typical of these injuries. So, expect a loss of range of motion of your neck if you have sustained a whiplash.

One of the things that I see in my office, and one that repeatedly comes up on MRI's is straightening of the cervical spine.  It is often seen after a whiplash trauma and is often considered by some doctors to be a normal variant, which is unlikely to be of any concern.  And, I'm sure many of the practitioners out there who are reading this are thinking, " big deal", everyone has this.  In fact many orthopedists are not concerned by this at all.  But, I studied this.  It is my job to tell it like it is, even if it goes against the normal thinking many of my colleagues.  I will tell you why this is something that clinicians should be aware of and in fact, should be concerned about.



You see, the curve, or lordosis, in the cervical spine is not there by accident.  In fact, its there actually to help buffer the spine and protect the spinal cord from shock due to the possibility of axial forces or downward compression from the head due to trauma.  Just think, if you had a spine which was as straight as a pencil, every time you even took a step, the joints of the spine would have to deal with the compressive forces and the possibility of injury or even fracture of a bone.  As an experiment, take that pencil that's on your desk, hold it in your hand, and now, jam it directly into a book or something on your desk.  Now, imagine doing the same thing with a pencil that has a slight c-shape curve to it.  I bet that you could feel the impact of that straight pencil going into the book, but the curved one is able to take or absorb some of the energy of the force.  You will feel that the curved one sent less of a shock up through your hand.   Think about that for a moment.

The next thing you have to be aware of is that the spine has supportive structures like the Anterior Longitudinal Ligaments (ALL) and Ligamentum Flavum (LF) which are often damaged from a whiplash injury. (3)  These ligaments connect from bone to bone, and in this case, your cervical vertebrae, which helps to keep these bones together and keep the normal cervical lordotic curve. An interesting study which confirms injures to these ligaments due to whiplash, was recently completed by Fice and Cronin in Ontario,and in fact, thet studied the minimal G-forces required to cause these ligamentous disruptions. (4)   Thus it is clear that these important ligaments in the cervical spine are there for supportive reasons.  When we see a spine of a patient post whiplash, very often we see the straightening which may be due to a disruption of these important pieces of connective tissue. (5)  Just as you wouldn't ignore an ankle sprain which involves  disruption of ligaments, you should also never ignore disrupted ligaments in the cervical spine.  I think we can all agree that this is a much more critical part of the human anatomy.

So, does this sound like something you want to ignore? These types of injuries without a doubt require some sort of rehab. If left alone, you can expect a permanent loss of function and/or pain. Up to 50% of individuals who suffer a whiplash will fail to recover.(1)  Other studies have the rate of recovery even worse. (2) The patient should be slowly rehabilitated using various methods. This, in my opinion is an emergency. It might not be a life or death emergency, but this injury could cause permanent loss of function of a body part, and sometimes a noticeable straightening and deformity.  It needs to be treated and treated right away in order to limit the amount of loss.

If you have a whiplash type injury, find your local chiropractor.  We are trained to help people hurt like this.  If you are in South Florida, you can call me to schedule an appointment.

I have two websites because I draw patients from both Miramar and Pembroke Pines. Check out my websites: www.MiramarChiropractor.com and www.PembrokePines-Chiropractor.com

Refrences:

1. Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S330-4.

Prognosis after whiplash injury: where to from here? Discussion paper 4.

Sterling M, Carroll LJ, Kasch H, Kamper SJ, Stemper B.

Source

Centre of National Research on Disability and Rehabilitation Medicine, The University of Queensland, Brisbane, Queensland, Australia. m.sterling@uq.edu.au

2. Injury. 2011 Jan;42(1):25-32.

Identifying predictors of early non-recovery in a compensation setting: The Whiplash Outcome Study.

Casey PP, Feyer AM, Cameron ID.

Source

Rehabilitation Studies Unit, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia. pcas0573@uni.sydney.edu.au, petrina@harvard.co.nz

3.  J Biomech. 2012 Aug 30. [Epub ahead of print]

The effects of ligamentous injury in the human lower cervical spine.

Devin Leahy P, Puttlitz CM.

Source

Orthopaedic Bioengineering Research Laboratory, Department of Mechanical Engineering, Colorado State University, Fort Collins, CO 80523, USA.

4.  J Biomech. 2012 Apr 5;45(6):1098-102. Epub 2012 Jan 28.

Investigation of whiplash injuries in the upper cervical spine using a detailed neck model.

Fice JB, Cronin DS.

Source

Department of Mechanical Engineering, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1. jfice@uwaterloo.ca

5.  Tidsskr Nor Laegeforen. 2010 Jan 14;130(1):29-32.

[Anatomy of the cervical spine].

[Article in Norwegian]

Holck P.

Source

Institutt for medisinske basalfag, Avdeling for anatomi, Universitetet i Oslo, Postboks 1105, Blindern 0317 Oslo, Norway. per.holck@medisin.uio.no