A case manager can make all the difference in a patient’s quality and comprehensiveness of care, serving as an important advocate in what often proves to be a difficult, complicated and confusing process.Perhaps one of the case manager’s most important roles is what the Case Management Society of America describes as “ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source.”
In Florida, that often means helping accident victims navigate the complex requirements of Florida’s Personal Injury Protection (PIP) law, which was complicated even further this spring by the 2012 Legislature’s sweeping reform measures. Many of those changes cut into motorists’ ability to enjoy the full protections the statute originally was designed to deliver. So it is critical that case managers working with accident victims become familiar with PIP’s newly amended provisions to ensure patients have access to all the coverage and reimbursement allowed by law.
In particular, it is essential that you know that under the new PIP law:
• Florida drivers no longer are eligible to seek reimbursement for their full $10,000 PIP coverage for any verifiable injury suffered in an auto accident. Only those injuries diagnosed as requiring “emergency” treatment qualify for full coverage under the new law. All non-emergency injuries, such as whiplash and back pain – among the most common – are eligible for a maximum of $2,500 in medical treatment.
• Only medical doctors, osteopathic physicians, dentists, physician assistants or ARNPs can diagnose injuries that qualify for emergency treatment and full coverage.
• Accident victims must seek treatment within 14 days to qualify for coverage.
• Massage therapy and acupuncture visits are no longer covered.
• A glitch that some fear leaves a six-month eligibility gap potentially allows insurers to stiff certain medical providers, such as doctors, chiropractors, medical schools and dentists, for legitimate PIP-related treatment costs between July 1, 2012, and Jan. 1, 2013. State Agency for Health Care Administration officials have interpreted the law to mean no such eligibility gap exists, so case managers should know patients are entitled to reimbursement for covered costs by these medical professionals, no matter what the insurer says.
• All motorists are eligible for up to $5,000 in funeral costs, separate from their ability to claim up to $10,000 in medical treatment bills. That means motorists can deplete their full $10,000 in medical coverage and, should they perish from their accident injuries, still be eligible for up to $5,000 for their loved ones to pay for a decent burial.
• Accident victims are still eligible for the full $10,000 in PIP coverage for 100 percent of replacement costs, which include child care, yard work, housekeeping and even transportation services if the injured motorist is the sole driver of the household. This is one of the few areas of PIP coverage untouched by the recent changes.
PIP’s ever-changing landscape can be complicated enough for even seasoned health care professionals to keep up with and understand. Imagine how confusing it would be for a patient traumatized by disruptive and often debilitating injuries suffered in an auto accident. This is one of the many times when case managers prove themselves to be the heroes they are, by seeing that their patients are covered as much as possible in getting the treatment they need.
