New South Florida PIP Law Shifts Burden to Medical Providers to Revise Rejected Claims
Effective January 1, 2013, Florida Statute §627.736 Required personal injury protection benefits; exclusions; priority; claims. will be changed to shift the burden to medical providers to revise any claims that have been rejected, in part or completely, by the insurer. Specifically, §627.736(4)(b) addressing BENEFITS; WHEN DUE, was changed from a block provision, to containing 6 separate subsections. Most of the subsections contain minor changes (1, 2, 4, 5, & 6), but seem to be separated in order to provide more clarity. Subsection (3), however, is a completely new provision which states, "If an insurer pays only a portion of a claim or rejects a claim due to an alleged error in the claim, the insurer, at the time of the partial payment or rejection, shall provide an itemized specification or explanation of benefits due to the specified error. Upon receiving the specification or explanation, the person making the claim, at the person's option and without waiving any other legal remedy for payment, has 15 days to submit a revised claim, which shall be considered a timely submission of written notice of a claim [Emphasis added]."
In the old statute, "[w]hen an insurer pays only a portion of a claim or rejects a claim, the insurer shall provide [...] an itemized specification of each item that the insurer had reduced, omitted, or declined to pay and any information that the insurer desires the claimant to consider related to the medical necessity of the denied treatment or to explain the reasonableness of the reduced charge [...] [Emphasis added]." At this point, if there was any dispute as to any rejected portion of a claim, the claimant could file a PIP suit and proceed accordingly. There was no provision addressing claim rejections due to "alleged errors," and there was no recourse, aside from filing a PIP suit, for the claimants to seek. With the new statute, the old provision (quoted above) remains essentially the same and can be found at §627.736(4)(b)(2). For claimants, however, subsection (3) creates an additional step.
It is likely that many of these alleged errors will be pointed out by insurance companies, and in turn, that many claims will be rejected in whole or in part because of such alleged errors. Attorneys will have to keep on their toes when calculating their clients' medical costs, and make sure to take into account any rejections by the insurer. When a claim is rejected in full, it will be in the attorney's best interest to make sure that the medical provider/claimant is aware of the claim rejection and that they are taking the proper steps to either revise the claim within the statutory 15 day period, or to find an alternative method of reimbursement if they decide not to drop the claim (i.e., require the patient to pay out-of-pocket, bill any applicable health insurance carrier, etc.). The same goes for when a claim is partially rejected. Florida attorneys should notify their clients of such claim rejections, and make sure that they are aware of any additional expenses that may be personally incurred because of the rejection. Although the burden is on the claimant (typically the medical provider on behalf of the patient) to work out their own billing issues, a prudent attorney will make sure that their client is notified and that this issue doesn't slip through the cracks. This will help ensure the client is protected.







