South Florida Hospital News
Tuesday January 19, 2021
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January 2021 - Volume 17 - Issue 7
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Ged Lawyers: Helping Healthcare Providers Collect PIP Payments

Florida’s No-Fault Personal Injury Protection (PIP) law can sometimes be quite confusing and frustrating for healthcare providers. At Boca Raton, FL-based Ged Lawyers, LLP, they can help you navigate this complex process, with the goal of obtaining fair and quick compensation.

For instance, Ged can help with the recovery of forgotten PIP receivable accounts through a retrospective audit. Under the Florida statute, they can go back five years and audit unpaid bills because the claim is based on a breach of contract. Identifying and pursuing unpaid and underpaid PIP claims for patients treated may result in the recovery of significant revenue.
 
“We can conduct an audit for hospitals or physician groups and find out where the money is through their EMR,” says Marius J. Ged, one of the partners with Ged Lawyers. “We’ve been successful in recovering lost revenue for current claims. Today, we have the ability to do this remotely which is a huge advantage for both us and for the clients. There’s a significant amount of money in these dead files or zero balance review cases.”
 
Ged acknowledges that while larger clients have an EMR set up, most smaller clients do not.
 
“In these cases, we can convert them from a manual audit to a remote audit,” says Ged. “We can educate them about scanning and digitizing certain documents and then allow us to create a HIPAA secure tunnel to retrieve that information.”
 
What can add to the confusion is that PIP cases are always changing and that can affect how bills are being paid by insurance companies, adds Chad Christensen, a partner with Ged Lawyers.
 
One major area involves the use of the Medicare fee schedule to adjust Florida PIP claims. Both the courts and the legislature have changed the rules, which have caused PIP insurers to re-evaluate their policy language and claims handling. The current statute requires that insurers reimburse 80 percent of reasonable expenses for medically necessary treatment.
 
“Many medical providers’ bills are paid at the allowable amount of 200 percent of Medicare Part B,” says Christensen. "When a provider bills less than 200 percent of Medicare Part B, the statute still requires the insurance company to either pay 80 percent of the 200 percent of Medicare Part B, or the total charge submitted.”
 
The difference in payment levels is considerable. For example, a provider charges $100 for an office visit, but under the statute, 200 percent of Medicare Part B, would be $110 for that office visit. PIP pays 80 percent of the reasonable charge.
 
“If a provider submits a charge for a $100 office visit, which is $10 less than the fee schedule amount, most insurance companies will pay 80 percent of the $100 charge submitted which is $80,” notes Christensen. “But technically under the statute, if they choose to limit payment pursuant to the fee schedule, they have to pay 80 percent of the fee schedule no matter what the provider charges.”
 
In this hypothetical scenario, $110 x 80 percent would require the insurance carrier to pay $88. The whole purpose of the enactment of the fee schedule was to take out a huge part of litigation of determining what is a reasonable charge for the medical services.
 
“A huge fight for many years was how to determine what was a reasonable amount,” says Christensen. “If the providers weren’t paid 80 percent of their charges, they were suing for whatever reduction there was. The statute was amended to allow insurance companies to elect these fee schedules to remove the litigation as to what a reasonable amount is. As a result, they are taking reasonableness out of the equation and now have to pay 80 percent of that particular fee schedule. But it gives the insurance carrier an option to pay the total charge submitted when a provider bills less than the 80 percent of 200 percent of Medicare.”
 
This is how it benefits the insurance company by paying the total charge. If the fee schedule amount for that same office visit is $200, and they choose to pay at the scheduled maximum charges, they pay 80 percent of the fee schedule amount, or $160 ($200 x 80 percent)—$60 more than what the provider charged.
 
“When you have this disparity, the insurance company has the option to pay the total charge submitted rather than 80 percent of the total charge,” says Christensen. “In this case, if the provider bills a lot less than the fee schedule amount, the insurance company rather than paying 80 percent of the fee schedule amount, can pay the total charge submitted.”
 
This is an issue prevalent today and being litigated because insurance companies are arguing that the policy language allows them to pay 80 percent of the bill if the provider bills less than the fee schedule amount.
 
There are several other issues that can affect a claim according to both Ged and Christensen, such as Medicare coding denials or insurance carriers taking Medicare reductions based upon nurse practitioners or physician assistants providing care or treatment.
 
“You can also have denials from carriers claiming that there is an unbundling of services and the provider cannot bill separately or the insurance companies paying the wrong fee schedule based upon their policy languages,” adds Christensen.
 
No matter the issue, Ged Lawyers has in-depth knowledge about PIP regulation and stay abreast of changes in insurance law, fighting tirelessly for clients for the compensation they deserve.

For more information, visit www.gedlawyers.com.

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