South Florida Hospital News
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January 2011 - Volume 7 - Issue 7


Hospitals and P.I.P.

Four ways to Boost your bottom-line in 2011

1) PIP Recovery Project:
Pull a 5-year historic report by “Auto Classification” accounts and determine how many accounts were paid under 80% of billed charges. Automobile insurance companies have historically reduced/denied hospital PIP claims knowing that hospitals do not typically pursue these types of claims. Upon receipt of the reduction/denial, the hospital will bill health/Medicare and accept an alternative/lower reimbursement, adjust the balance and let the PIP carrier off the hook. Florida law permits a 5-year statute of limitations for breach of contract claims. The recovery over a 5-year period may turn worthless A/R into a valuable commodity within 60 days.
2) Unknown/Unbilled PIP Policies:
PIP insurance covers drivers, passengers and pedestrians struck by a motor vehicle. Once a motor vehicle accident occurs, the hospital’s registration/PFS department is lucky at best if a driver happens to be carrying his/her PIP insurance information to properly bill the claim. However, it is almost certain that a passenger or pedestrian struck by the motor vehicle will not know the PIP insurance policy information belonging to the owner of the vehicle. The end-result will most likely cause that claim to be billed through alternative insurance such as health, Medicare or worse-self-pay. Having a legal vehicle to find and collect against the responsible PIP/MVA carrier at the respective higher reimbursable rate will certainly boost your bottom-line.
3) Deductible Claims:
Florida Statutes requires PIP deductibles to be applied to 100% of the charges. However, virtually all PIP carriers are improperly subtracting the deductibles after applying a fee schedule.
For instance, suppose you billed a $1,500 PIP/MVA claim that contained a $1,000 deducible.
The proper calculation is as follows:
$1,500 - $1,000 (deductible) = $500 x 75% of U & C (assuming this applies, see number 4 below) = $375 x 80% = $300 reimbursement
The current/improper calculations being used by PIP/MVA carriers is as follows:
$1,500 x 75% of U & C = $1,125 - $1,000 (deductible) = $125 x 80% = $100
$1,500 x 75% of U & C = $1,125 x 80% = $900 - $1,000 (deducible) = (100)
Due to the fact that hospitals are subject to the deductible in most PIP claims, the recovery can be quite substantial.
4) Fee Scheduled claims 75% (net 60%) vs. 80% of Usual and Customary:
Effective January 15, 2008, the No-Fault/PIP Statute was amended. Under Section 627.736, Florida Statutes, hospitals are reimbursed at 80% of 75% of their U & C. However, emergency room physicians who provide “emergency services and care” are entitled to 80% of their U & C.
The definition of “Emergency Services and Care” under Section 395.002(9), Florida Statutes reads:
“Emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility.”
Most if not all E.R./E.D. services are rendered “under the supervision of a physician.” This attorney has a pending declaratory action on behalf of a Florida hospital challenging the 75% (net 60%) reductions applied to Florida hospitals for “emergency services and care” rendered by hospitals. If we are successful, this will increase the PIP reimbursements for all Florida hospitals by 20%. Imagine what your hospital can do with an additional 20% added to your bottom-line. Contact Celler Law, P.A. at (954) 972-8011 to find out how to lend your support on this major decision.
Bobbie Celler, Esq., Celler Law, P.A., can be reached at (954) 972-8011 or or visit
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