Frequently Asked Questions
What is Personal Injury Protection (P.I.P.)?
P.I.P. stands for Personal Injury Protection. It is also known as "no-fault" coverage. All Florida motor-vehicle owners are required to maintain P.I.P. by law. It pays medical expenses related to a motor-vehicle collision up to the first $10,000 regardless of fault.
How do I know if a patient is covered through P.I.P.?
The patient should have an auto insurance card. Make a copy. If they reported the car collision then they should have been assigned a claim number from the P.I.P. insurance company. If the patient has treated with other medical providers before presenting to your office, you should ask the P.I.P. insurance company to provide a "P.I.P. payment log" so that you can determine how much, if any, coverage is remaining. Remember that once that $10,000 policy limit is reached then benefits have exhausted and, for the most part, no further payments will be made.
Who is covered by P.I.P.?
P.I.P. covers the owner of the motor-vehicle, resident-relatives, and passengers injured in the owner's motor-vehicle.
Must I obtain prior approval from a P.I.P. insurance company before treating a P.I.P. patient?
State law does not require prior approval for P.I.P. insurance.
What if the patient caused the accident?
The patient is still covered through P.I.P. insurance.
What types of services does a P.I.P. insurance company pay for?
P.I.P. insurance covers eighty percent of all reasonable expenses for medically necessary medical expenses related to the auto collision. Since 2008, P.I.P. insurance companies are only obligated to pay for treatment which is reimbursable under Medicare or Florida Worker's Compensation.
What type of information do I need from the patient before treating the patient?
First, you need to obtain the necessary facts related to the patient's injuries and the car collision. You should also have the patient sign an "Assignment of Benefits" and obtain a copy of their insurance card so you know exactly which insurance company to bill. Don't forget to have the patient sign a "Standard Disclosure and Acknowledgement Form" as this could preclude you from getting paid.
How much can I charge for my services?
You can charge as much as you like. Remember that the same amounts must be charged across the board to every type of party (health, Medicare, worker's comp, and P.I.P.). P.I.P. insurers are allowed to reduce your bills to the usual and customary rates in your area. Also, since 2008, most insurers (though not all) are permitted to pay at 200% of Medicare Part B or 80% of Florida's Worker's Compensation rates. If a service, supply, or care is not reimbursable under Medicare or Worker's Compensation then the P.I.P. insurance company is not obligated to pay.
Are there special billing requirements for P.I.P.?
Bills must be submitted on a properly completed CMS-1500 or UB 92 billing form. Supporting medical documentation should also be provided. The initial set of bills should also include a properly completed "Standard Disclosure and Acknowledgement Form" and an "Assignment of Benefits."
What is the deadline to submit my bills to the P.I.P. insurance company?
Bills should be sent to the P.I.P. insurance company within 35 days of the date the service was rendered. However, if a patient gives the medical provider the wrong insurance information then the medical provider has 35 days from the date it receives the correct insurance information. Additionally, if a medical provider submits a "Notice of Initiation of Treatment Form" to the P.I.P. insurance company within 21 days of the first date of service via certified mail then the medical provider can submit their bills within 75 days.
Am I obligated to keep my sign in sheets?
Yes. You should hold on to your sign in sheets. You should not submit them with the bills. Also, be careful about showing the sign in sheets without redacting other patient names as this could be a violation of HIPAA laws.
What should I do if the P.I.P. insurance company instructs my patient to attend an Independent Medical Examination (I.M.E.) for a second opinion?
Instruct the patient to attend the I.M.E. as they are required to cooperate with the insurance company's request. The patient is allowed to have someone accompany them to the examination, including their treating physician and/or attorney. The patient is also allowed to have the examination videotaped.
What should I do if a P.I.P. insurance company reduces my bills?
Just because a billion dollar company tells you it is reducing your bills doesn't mean that it is legal. Insurance companies reduce bills in most cases for the sole reason of saving money. By accepting insurance premiums from their insured and refusing to pay your bills, they are making money. If an insurance company wants to reduce your bills then give our office a call so we can determine if the reduction is valid. Our office will make this determination free of charge.
What should I do if a P.I.P. insurance company refuses to pay for future treatment?
Again, insurance companies make money by refusing to pay valid bills. Contact our office and let us make the determination. In many cases, the insurance company obtains another doctor's "independent" opinion in order to deny benefits. Some of these doctor's, though not all, make six figures a year by wrongfully denying benefits to patients who need treatment. Our office has been successful in exposing these so called "independent" doctors and recovering money for our clients.
What should I do if a P.I.P. insurance company requests additional information?
You should cooperate with the request to the best of your ability. If you believe an insurance company is asking for too much information then feel free to contact our office and get our opinion. Again, this is at no charge to you.
How much will it cost to hire an attorney to handle my P.I.P. claim against the insurance company?
Our office never charges an out-of-pocket fee to clients. You will never have to write a check payable to our office. If an insurance company makes a payment in response to our demand letter then we keep the interest and a 10% penalty which the insurance company is obligated to pay in addition to your medical bills.
Why should I use an attorney to handle my P.I.P. claim?
Why not? P.I.P. is a very technical area of law and our office doesn't charge you an out-of-pocket fee. We only recover money if we are successful at collecting money on your behalf.
Can't I ask the personal injury attorney representing the patient to handle this type of claim?
Even if you work with a great personal injury attorney, in most instances, they do not handle P.I.P. claims on behalf of medical providers. As previously stated, it is a very technical area of law and is constantly changing.
How do I get the full benefit of the $10,000 of PIP benefits (as opposed to being limited to $2500) that I am required by law to pay for?
- Seek initial treatment within 14 days of your accident with an MD/DO/Dentist/Chiropractor, or at the hospital or a facility that owns/is owned by a hospital or an ambulance/EMT.
- Obtain a determination from the MD/DO/Dentist or their PA or ARNP that you had an emergency medical condition (EMC).
Must an EMC be determined on the first visit to a health care provider?
No. The statute does not give a specific timeframe in which an EMC must be determined.
Can a provider I see for follow up care determine the EMC?
Yes, with the exception of a chiropractor or physical therapist.
Can my Chiropractor determine EMC?
No! Not under any circumstances.
If I receive acupuncture or massage, will my PIP benefits pay for it?
No.
What if massage or acupuncture is done in an MD's office or a Chiropractor's office?
No.
What if the MD or DO gives me a referral for massage or acupuncture?
No.
If I am treated by a physical therapist, will my PIP benefits pay for it?
Yes, but only with a referral from an initial treating provider for treatment consistent with the injury and initial diagnosis.
Can my Physical Therapist determine EMC?
No.
Can I see my Chiropractor initially?
Yes.
Do I need a referral from an MD to see my Chiropractor for follow up care?
No.
Is there a list of injuries/symptoms/complaints that compromise an emergency medical condition?
No.
Is a sprain/strain an EMC?
Unknown at this time.
Is a fracture of a finger an EMC?
Unknown at this time.
Is a severe headache an EMC?
Unknown at this time.
Are muscle spasms and tightness an EMC?
Unknown at this time.