Monday, August 8, 2016

Untimely Billing In Personal Injury Protection (“PIP”); The 35 Day Rule Of PIP


As medical providers, it is always important to have a great billing department to ensure that services are being coded correctly, sent to the correct place and served timely to the medical provider. One of the issues I speak to my clients about on a weekly basis is timely filing of claims, especially when the patient initially gives them the wrong information.

When a patient is in a car crash and the other person is to blame, what we find happens is when asked for the insurance information they can tend to give the insurance information of the “At-Fault” insurance provider. When dealing with Personal Injury Protection “PIP”, otherwise known as “The Florida No-Fault Law” the information you are seeking is for their own insurance. Meaning it is important to have every person in the office know the difference between a BI claim operating under a letter of protection and a claim that is being billed to PIP. So what happens when, even though the staff is educated, the patient is just not paying attention and gives you the wrong insurance company, or better yet, does not own a car and was in a friends vehicle and doesn’t know their friends insurance?

Under The Florida No Fault Statute  (Fla. Stat. 627.736(5)(c)) is where you find the 35 day rule. It states:

(c) With respect to any treatment or service, other than medical services billed by a hospital or other provider for emergency services and care as defined in s.
395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 35 days before the postmark date or electronic transmission date of the statement, except for past due amounts previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement. The injured party is not liable for, and the provider may not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable.

1. If the insured fails to furnish the provider with the correct name and address of the insured’s personal injury protection insurer, the provider has 35 days from the date the provider obtains the correct information to furnish the insurer with a statement of the charges. The insurer is not required to pay for such charges unless the provider includes with the statement 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.

So what does the above mean to you, the medical provider? It means different things for different scenario’s. Here are the most common that I see on a week to week basis.

Scenario #1- Patient gives medical provider wrong information, medical provider bills the wrong company, gets a denial letter, then sends the denial letter with proof of timely mailing to the correct insurance company.

This is exactly what is supposed to happen. Once you found out that you reasonably relied on the incorrect information you provided the new company proof of timely submission to the wrong company with the explanation of the wrong information. The correct insurance company should deem this timely and pay your bill accordingly. If they do not contact Dolman Law Group at derek@dolmanlaw.com or 727-222-6922.

Scenario #2- Patient gives you wrong medical provider, you bill timely to the wrong company, get denial letter and then send in bills to insurance company without evidence provided by the insured or the denial letter or proof of mailing.

In this scenario, assuming that the denial came after the 35 days from the denial letter arriving, because you failed to properly follow the statute and submit the bills accompanied by documentary evidence that was provided by the insured and one either the denial letter or proof of mailing, your claim will be deemed untimely.

Scenario #3- The patient does not know anything about the PIP insurance and gives you no information so you don’t bill any PIP carrier. A few months go by and the attorney tells you the correct insurance company. You then bill the correct insurance company and explain to them what happened.

Your bill will be deemed untimely. But why? While this may seem similar to a denial, and resubmission the critical part of the statute that have not been followed is the timely submission to a carrier. Because, no carrier was billed you cannot then comply with the portion that makes you attach a timely submission or a letter of denial. Therefore, your billing will be untimely. So what should you do in this scenario?

You must force the issue with the patient or with their attorney to find out the insurance company or their best theory on who the insurance company is so you can bill someone. If you get back a denial and now after some time has passed you find the correct insurer then within the 35 days of the denial you can submit to the correct insurance company and it should be deemed timely. If it is not, then call Dolman Law Group at
derek@dolmanlaw.com or 727-222-6922.

Worst case scenario at the onset of treatment you might need to make your patient guess who the insurance company is. At least then you can bill someone. I would recommend waiting until closer to the 35th day (taking into account mailing time) to submit it to give your patient a chance to find the true insurer. Then if they are wrong it gives you more time to find the true one. In the end, it will leave you in a much better position than not billing during the first 35 days where you have zero chance of being reimbursed.

If you have a patient whose bill is being improperly denied for untimely billing or have any questions regarding proper billing reach out to Dolman Law Group at derek@dolmanlaw.com or call (727) 222-6922.

Dolman Law Group
1663 1St Ave S.
St. Petersburg, FL 33712
(727) 222-6922