Page 23 - January 2021 South Florida Hospital News

Cover Story: Ged Lawyers:

Helping Healthcare Providers Collect PIP Payments

Continued from page 1
scanning and digitizing certain documents and then allow us to companies to elect these fee schedules to remove the litigation as
create a HIPAA secure tunnel to retrieve that information.” to what a reasonable amount is. As a result, they are taking rea-
What can add to the confusion is that PIP cases are always sonableness out of the equation and now have to pay 80 percent
changing and that can affect how bills are being paid by insurance of that particular fee schedule. But it gives the insurance carrier
companies, adds Chad Christensen, a partner with Ged Lawyers. an option to pay the total charge submitted when a provider bills
One major area involves the use of the Medicare fee schedule to less than the 80 percent of 200 percent of Medicare.”
adjust Florida PIP claims. Both the courts and the legislature have This is how it benefits the insurance company by paying the
changed the rules, which have caused PIP insurers to re-evaluate total charge. If the fee schedule amount for that same office visit
their policy language and claims handling. The current statute is $200, and they choose to pay at the scheduled maximum
requires that insurers reimburse 80 percent of reasonable expens- charges, they pay 80 percent of the fee schedule amount, or $160 Discover
s
es for medically necessary treatment. ($200 x 80 percent)—$60 more than what the provider charged. South University
“Many medical providers’ bills are paid at the allowable amount “When you have this disparity, the insurance company has the
of 200 percent of Medicare Part B,” says Christensen. "When a option to pay the total charge submitted rather than 80 percent of
provider bills less than 200 percent of Medicare Part B, the statute the total charge,” says Christensen. “In this case, if the provider
n
still requires the insurance company to either pay 80 percent of bills a lot less than the fee schedule amount, the insurance com- Whether you’re just starting in the field
v
the 200 percent of Medicare Part B, or the total charge submitted.” pany rather than paying 80 percent of the fee schedule amount, of nursing, or looking to move your
The difference in payment levels is considerable. For example, can pay the total charge submitted.” career forward, South Univer rsity can
a provider charges $100 for an office visit, but under the statute, This is an issue prevalent today and being litigated because elevate your journey as a car regiver.
200 percent of Medicare Part B, would be $110 for that office visit. insurance companies are arguing that the policy language allows
PIP pays 80 percent of the reasonable charge. them to pay 80 percent of the bill if the provider bills less than the
“If a provider submits a charge for a $100 office visit, which is fee schedule amount.
$10 less than the fee schedule amount, most insurance companies There are several other issues that can affect a claim according
will pay 80 percent of the $100 charge submitted which is $80,” to both Ged and Christensen, such as Medicare coding denials or West Palm Beach, Florida

notes Christensen. “But technically under the statute, if they insurance carriers taking Medicare reductions based upon nurse
choose to limit payment pursuant to the fee schedule, they have practitioners or physician assistants providing care or treatment. From all of us at
to pay 80 percent of the fee schedule no matter what the provider “You can also have denials from carriers claiming that there is South University, West Palm
m Beach
charges.” an unbundling of services and the provider cannot bill separately thank you for your servi ce!
In this hypothetical scenario, $110 x 80 percent would require or the insurance companies paying the wrong fee schedule based
the insurance carrier to pay $88. The whole purpose of the enact- upon their policy languages,” adds Christensen.
ment of the fee schedule was to take out a huge part of litigation No matter the issue, Ged Lawyers has in-depth knowledge Get Started today! Call us at
u
of determining what is a reasonable charge for the medical serv- about PIP regulation and stay abreast of changes in insurance law, 866.242.1840 or visit t
ices. fighting tirelessly for clients for the compensation they deserve. SouthUniversity .edu/W estPalmBeach
“A huge fight for many years was how to determine what was
a reasonable amount,” says Christensen. “If the providers weren’t For more information,
paid 80 percent of their charges, they were suing for whatever visit www.gedlawyers.com.
reduction there was. The statute was amended to allow insurance

South Florida Hospital News southfloridahospitalnews.com January 2021 23