Receiving Payment Under Fla. Statute
627.736 (2009) - The PIP Statute
•
PIP pays 80% up to $10K of medical
expenses as a result of bodily injury,
sickness, disease, or death arising out of
ownership, maintenance, or use of a motor
vehicle. PIP pays 60% up to $10K of lost
wages.
•
PIP benefits “shall be overdue if not paid
within 30 days after the insurer is furnished
written notice of the fact of a covered
•
What is written notice?
HCFA/CMS form; Medical records;
Disclosure and acknowledgment form
(“D&A” form).
•
If such written notice is not furnished to
the insurer as to the entire claim, any
partial amount supported by written
notice is overdue if not paid within 30
days after such written notice is furnished
to the insurer.”
Timely Filing of Claims-
Required-•
Claims must be submitted within 35 days of the date(s)
of service listed on the claim.
•
The exception is that If the provider submits
a notice of
initiation of treatment
within 21 days after the 1st
exam or tx, then the provider has no more than 75 days
from the “postmarked date of the statement " to submit
the claim to the insurer.
•
If the insured does not furnish the provider with the
correct name and address of their PIP insurer, the
provider has
35 days from the date the provider
obtains the correct information to submit the claim
to the insurer.
Timing continued…
•
The provider must provide documentary evidence that
was provided by the insured during the 35 day period
demonstrating that the provider reasonably relied on
erroneous information from the insured and either:
a. A denial letter from the incorrect insurer; or
b. Proof of mailing, which may include an
affidavit under penalty of perjury, reflecting timely
mailing to the incorrect address or insurer.
Timing continued…
What happens if you submit a claim, and the insurance
company responds, that the claim was not timely filed?
-
Keep evidence in the client’s chart/billing
information of timely filing, such as:
Proof of mailing:
1)
Send the bills
certified mail and keep hard
copies of the current claim forms.
2)
Mail ledger.
3)
Copy of envelope.
•
Establish a billing policy and procedure
requiring bills to be submitted within 35 days
of the date of service.
•
Note the file or patient ledger as to the date
when the bill was mailed out.
WHAT HAPPENS IF INS. CO. FAILS TO
PAY CLAIM?
-
SEND A DEMAND LETTER IMMEDIATELY
Pursuant to Florida Statute 627.736 (10) the
insurance company has 30 days to respond to the
demand letter.
Include in the demand letter:
○
the claim number or policy number, patient name,
assignment of benefits, name of provider,
statement specifying the exact amount owed to
date; including the date of service.
Attach copies of HCFA/CMS form.
Search
for the insurance company’s address with
appropriate PIP Contact Name:
Failure to pay continued…
•
Go to:
http://www.floir.com/companysearch/
.
Type in the insurance company name, and use
the PIP contact name and address.
•
For IME cutoffs- include a proposed treatment
plan.
•
If benefits have exhausted, the insured is
responsible for payment, and the insurer is not
required to pay any more than the $10K
available in benefits.
•
If no payment is received, AND benefits
remain, submit the claim to an attorney to file a
PIP suit immediately.
DEMAND FOR PAYMENT PURSUANT TO 627.736(10), Fla. Stat. (2009)
CERTIFIED MAIL, RETURN RECEIPT REQUESTED:
GEICO
Attn: George W. Rogers
PO BOX 9091Macon, GA 31208
RE: Patient Name: ______________ (Assignment Attached) Claim Number: ______________
Dear Mr. Rogers:
This is a demand letter under pursuant to Florida Statute 627.736 (10) (2009).
Enclosed are the itemized statements, for _______ through _______dates of service. The amount at issue is $_________. Please remit payment in
the amount of $___________. Under Fla. Stat. 627.736, it is not mandatory that the aforementioned bills be paid pursuant to 200% of Medicare fee schedule. Please provide the undersigned with a PIP log immediately.
If you have any questions about the bills at issue, please compare the attached ledger to your explanation of benefits and please note we dispute each and every reduction and nonpayment. If you still have questions or need additional
documentation, please let us know. If you respond to this demand letter, we will assume this demand letter is acceptable. We are relying on you to tell us if this demand letter or this pre- suit notice is defective in any way before suit is filed.
POSTAL COSTS REIMBURSEMENT IN THE AMOUNT OF $______ & APPLICABLE PENALTY OF 10% AS PERMITTED BY FLORIDA LAW, IS HEREBY REQUESTED TO BE MADE PAYABLE TO: __________________________.
PAYMENT IN THE AMOUNT OF $__________ & STATUTORY INTEREST PERMITTED BY FLORIDA LAW IS HEREBY DEMANDED AND MADE PAYABLE TO:
_________________.
Pursuant to Florida Statute 627.4137 and 627.736, and 627.7401, respectively, a demand is hereby made for the following:
1) A copy of the policy, declarations page, and PIP payout log pursuant to Florida Statutes 627.4137, 627.736(6)(d), and 627.7401.
2) A copy of the explanation of benefits for each bill not paid or reduced; 3) A copy of any EUO, statement, or recorded transcripts;
4) A copy of all IME reports;
5) A copy of the letter(s) demanding the patient to appear at an IME, an EUO, or a telephonic recorded statement and proof of mail; and
6) A copy of any and all information obtained under the provisions of 627.736, as required by the provisions of 627.736 (6)(d) Florida Statutes.
You are hereby given notice that you must pay the amounts claimed, without reduction,
under the terms of the applicable policy and 627.736, Fla. Stat. (2009), within thirty (30) days of receipt of this letter or we will file suit against you without further notice. Demand is made for the medical payments, postage, penalty and the interest to be paid to
_________. All checks and documents are to be mailed to _______________ at the below referenced address within thirty (30) days.
If you decline to make payment pursuant to this letter, please immediately reserve benefits at least equal to the disputed amount.
