Legal Updates From David S. Ged, P.A.

Florida Motor Vehicle No Fault Law. ss. 627.730 - 627.7405, F.S., has been reenacted and revised as of January 1, 2008. Personal injury protection coverage will continue to pay 80% of medical expenses up to $10,000.00. However, the benefits are limited to services and care lawfully provided, supervised, ordered or prescribed by a licensed physician, osteopath, chiropractor or dentist

Follow up:

or provided by:

“A hospital or ambulatory surgical center;
“An ambulance or emergency medical technician that provided emergency transportation or treatment;
“An entity wholly owned by physicians, osteopaths, chiropractors, dentists, or such practitioners and their spouse, parent, child or sibling;
“An entity wholly owned by a hospital or hospitals; or
“Licensed health care clinics that are accredited by a specified accrediting organization.

Licensed health care clinics that:
“Have a medical director that is a Florida licensed physician, osteopath, or chiropractor;
“Have been continuously licensed for more than 3 years or are a publicly traded corporation; and
“Provide at least four of the following medical specialties: general medicine, radiography, orthopedic medicine, physical medicine, physical therapy, physical rehabilitation, prescribing or dispensing outpatient prescription medication, or laboratory services.

Changes for treatment of injured persons (Fee schedule changes):
The insurer may limit reimbursement to 80% of the following schedule of maximum charges;
“For emergency transport and treatment; 200% of Medicare.
“For emergency services and care provided by a hospital, 75% of the hospital’s usual and customary charges.
“For emergency services impatient care rendered by a physician or dentist; usual and customary charges in the community.
“For hospital impatient services other than emergency services and care; 200% of Medicare Part A prospective payment applicable to the specific hospital providing the impatient services.

“For hospital outpatient services, other than emergency services and care; 200% of Medicare Part A Ambulatory payment Classification applicable to the specific hospital providing the outpatient services.

For all other medical services, supplies, and care, 200% of Medicare Part B fee schedule for 2007 unless such services , supplies or care are not reimbursable under Medicare Part B, the insures may limit reimbursement to 80% of the maximum reimbursable allowance under the current worker’s compensation fee schedule. Services, supplies, or care that is not reimbursable under Medicare or worker’s compensation is not required to be reimbursed by the insurer.

The Medicare 2007 fee schedule is to be used in figuring the 200% charge. Providers will not have to accept a lower fee schedule than the 2007 schedule in the event Medicare continues to reduce fees annually. “ If an insurer limits payment as authorized above, the provider may not bill or attempt to collect from the insured, except the co-payment amounts not covered by the PIP coverage, deductibles or if benefits exhaust.

Reserve $5,000 of PIP benefits for 30 days.
The insurer must reserve $5,000.00 for payment to physicians licensed to provide emergency services and care or dentists if such care has been provided. The amount required to be held in reserve may be used only to pay claims from such physicians or dentists until 30 days after the date the insurer receives notice of the accident. After the 30 day period the remaining amount of reserve will be released to pay other claims.

Demand letter (Statute changed to 30 days for insurer to respond)
Demand letters are now governed under sec. 627.736(10) and must “include assignment of benefits, claim number or policy number, name of provider, statement specifying each exact amount, date of service and the type of benefit claimed to be due
“For future treatment requested include the above and proposed treatment plan.
“All demand letters must be certified mail with return receipt requested.

Mandatory consolidation of PIP Claims:
“All PIP claims against an insurer related to the same provider for the same injured person must be brought together in a single lawsuit, unless good cause is shown for separation.

Death Benefits:
“Clarifying current law the PIP death benefits is $5,000.00 or the remainder of unused PIP benefits, whichever is less.

Timely filing of claims (Same as prior to 10/1/2007):
Claims must be submitted within 35 days of the dates of service listed on the claim.

“The exception is that a notice of initiation of treatment is submitted to the insurer within 21 days including statement. The provider then has no more than 75 days from the postmarked date of the statement.
“If the provider does not submit claims within the 35 day period the provider must submit the corrected claim forms to the insurer with a denial letter from the incorrect insurer if erroneous information was relied upon from the insured and or proof of mailing. For instance, if there is no documentation available neither the insurer nor the insured are responsible for payment with the exception of client’s co-payment not covered by personal injury protection.

Suggestion: always certified mail and keep hard copies of the current claim forms.

Resources:
Medicare website to look up specific codes is: http://www.cms.hms.gov/apps/ama/license.asp?file=/pfslooup/02_PFSsearch.asp

Worker’s Compensation fee schedule just came out on October 18, 2007. Visit website http://www.fldfs.com/WCAPPS/CPT/CPT_Agree8.asp
Warning 300 pages, use for looking up codes.