Frequently Asked Questions — Medical Providers

1. What is PIP?
2. Who is covered by PIP insurance?
3. How do I know if a patient has PIP coverage?
4. Must I obtain prior authorization from the insurance company before treating a patient?
5. What if the accident was the patient’s fault?
6. What services must the insurance company pay for?
7. What information do I need from the patient before treatment begins?
8. What may I charge for my services?
9. What are the billing requirements?
10. Are there deadlines for submitting my bills?
11. Do I have to keep my sign in sheets?
12. What should I do if my patient is told to attend an Independent Medical Examination (IME)?
13. What rights do I have if my charges are reduced by the insurance company?
14. What can I do if the insurance company refuses to pay for any further treatment?
15. How do I respond if the insurance company requests additional information?
16. How do I pursue a claim for PIP benefits?
17. What will it cost me?
18. If I pursue a PIP claim, can I still seek payment from the patient?
19. Why do I need an attorney to pursue a PIP claim?
20. Don’t all personal injury attorneys handle these type of claims?

1. What is PIP?
   “PIP” is an acronym for personal injury protection or “no-fault” coverage that all Florida vehicle owners are required by law to maintain.
2. Who is covered by PIP insurance?
   PIP covers the vehicle owner, resident relatives and passengers injured in the owner’s vehicle. In some cases, pedestrians injured by another vehicle may also be covered.
3. How do I know if a patient has PIP coverage?
   Check the patient’s insurance card and make a copy. If they have reported the accident, the insurance company should already have assigned an adjuster and a claim number and you should be able to find out this information over the telephone. If the patient has treated with other medical providers or a hospital before presenting to your office, you should ask the insurance company to provide a “PIP payment log” so that you can determine how much coverage is remaining on the policy. The patient may also have a wage loss claim being paid out of the PIP benefits.
4. Must I obtain prior authorization from the insurance company before treating a patient?
   No.
5. What if the accident was the patient’s fault?
   The patient is still covered regardless of fault.
6. What services must the insurance company pay for?
   Eighty percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices, and medically necessary ambulance, hospital, and nursing services. In some cases, the patient may also have medical payments coverage that will cover the other 20%.
7. What information do I need from the patient before treatment begins?
   First, you need to know the circumstances of the patient’s injury. In some cases, there may not be coverage for the accident. You should also obtain the patient’s insurance card so that you know exactly which insurance company to bill. Some insurers, like Progressive, have multiple companies operating in Florida. You should also have the patient sign an assignment of benefits before treatment begins. Finally, at the initial treatment, the patient or guardian must countersign a Disclosure & Acknowledgement Form.
8. What may I charge for my services?
   You may charge whatever you feel is reasonable. However, the PIP insurance company is only required to pay 200% of the applicable Medicare Part B fee schedule. However, if such services, supplies, or care are not reimbursable under Medicare Part B, the insurer may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers' compensation, as determined under Florida Statute 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care are provided. Services, supplies, or care that are not reimbursable under Medicare or workers' compensation are not required to be reimbursed by the insurer. There are some exceptions to the above fee schedule for emergency transport or hospital services.
9. What are the billing requirements?
   Bills must be timely submitted on properly completed CMS-1500 or UB 92 billing forms. All bills must have accurate CPT, HCPCS or ICD-9 codes in effect for the year the services were rendered. Medical documentation in the form of office notes describing the services should also be provided. The initial billing must be accompanied by a properly completed Disclosure & Acknowledgement Form approved by the Department of Financial Services which must be signed by the patient or the patient’s legal guardian. The name and the license number of the medical provider must be on the form as well as the accurate name and address of the billing entity and the location where the service was provided. Finally, if the patient has assigned benefits to the medical provider, a copy of the assignment must accompany the initial billing.
10. Are there deadlines for submitting my bills?
    Yes. Bills must be submitted within 35 days of the date the service was rendered.
11. Do I have to keep my sign in sheets?
    Yes. They need not be furnished with the bills but they must remain on file in your office.
12. What should I do if my patient is told to attend an Independent Medical Examination (IME)?
    Contact us immediately. The patient’s policy requires that he or she cooperate with the insurance company which includes attending an IME if reasonably requested. However, the patient has rights such as the right to have someone accompany them to the IME, have it videotaped, as well as the location of the exam.
13. What rights do I have if my charges are reduced by the insurance company?
    If you have not been properly reimbursed for your services, we can bring an action on your behalf to obtain the proper reimbursement as well as interest.
14. What can I do if the insurance company refuses to pay for any further treatment?
    Contact us. The insurance company can only withdraw treatment if it has obtained a proper report by a medical provider licensed under the same chapter that you are that states that further treatment is either not reasonable, not medically necessary, or not related to the accident. Even if they obtain such a report, we can usually obtain proper reimbursement for you.
15. How do I respond if the insurance company requests additional information?
    Depending upon the nature of the request, you should be cooperative. You can only take action against the insurance company if your bill is overdue. Under Florida law, a bill is not overdue if the insurer has requested additional information that has not been provided. Many times, a request for more information will be reflected in the comments in the Explanation of Benefits (EOB) form.
16. How do I pursue a claim for PIP benefits?
    You must first be sure that you have complied with all of the billing requirements and that your bills have been properly submitted. You must also send the insurance company a very specific pre-suit demand letter which gives them an additional 30 days to pay the claim. If the claim still remains unpaid, contact us.
17. What will it cost me?
    Nothing. I know that sounds unbelievable, but we handle these matters on a contingent fee basis. If we do not obtain proper reimbursement for you, we receive no payment. If we do prevail in your claim, our fees will be paid by the insurance company. You will never receive a bill from us for attorney’s fees or costs.
18. If I pursue a PIP claim, can I still seek payment from the patient?
    Yes. You do not give up your right to seek payment from the patient because you also seek reimbursement from the insurance company.
19. Why do I need an attorney to pursue a PIP claim?
    PIP is a highly technical, highly specialized area of the law with many prerequisites and deadlines that must be met. Failure to meet any of these may result in no reimbursement for you or possibly even your having to refund money to the insurance company. In certain circumstances, you could expose yourself to a claim of insurance fraud.
20. Don’t all personal injury attorneys handle these type of claims?
    Absolutely NOT. In fact, very few attorneys in Northwest Florida are experienced in handling PIP matters. The law in this area changes rapidly and most personal injury attorneys do not have the means, or the desire, to stay current in this area. For these reasons, you need to seek help from an attorney with PIP experience and a proven track record of success.

FAQs — Accident Victims