Two months to go: Florida PIP law 10 key changes for 2013 impact health care providers and insurers alike

Consider the 2012 PIP law changes from the perspective of health care providers treating auto injury patients in 2013. Some providers may see reduced payments. Massage therapists and acupuncturists are frozen out. Hospitals and most physician practice groups could actually benefit from limitations on other providers.

For insurers and health care providers alike, procedures will need to be modified. The effective date for most changes is January 1, 2013 - barely two months away. A summary of 10 key PIP law changes is presented below.

The New Law

A difficult challenge for Florida’s Legislature in 2012 was attempting to curtail the rising costs of no-fault automobile, personal injury protection (PIP) insurance. The final product, House Bill 119 or Chapter 2012-197 of Florida Laws, became law on July 1, 2012. Changes discussed below have a January 1, 2013 effective date, unless otherwise noted.

Change No. 1 – 14-Day Initial Service (“Use it or Lose it”)

This is one of the more striking changes in the new law. An insured must seek initial medical services and care within 14 days after the motor vehicle accident. If that new deadline is not met, then no medical benefits are available under PIP.

To qualify under the 14-day rule, the “initial services and care” must meet one of these requirements: (1) be lawfully provided, supervised, ordered, or prescribed by one of the following Florida licensed providers: (a) medical physician, (b) osteopathic physician, (c) dentist, or (d) chiropractic physician; or (2) be provided in a hospital or in facility that owns, or is wholly owned by, a hospital; or (3) be provided by a person or entity licensed to provide emergency transportation and treatment (e.g., an ambulance).

Change No. 2 – Non-Emergency Treatment Limited to $2,500

This is one of the more complicated changes in the new law. PIP medical benefits remain at $10,000 only if the insured has an emergency medical condition (EMC). If it is determined that there was no EMC, then medical services are limited to $2,500.

There are some differences in the types of providers who can determine whether there is an EMC (compared with those who can provide the 14-day initial service). EMC can be determined only by the following Florida licensed providers: (a) medical physician, (b) osteopathic physician, (c) dentist, (d) physician assistant, or (e) advanced registered nurse practitioner. A chiropractic physician is not authorized to make this determination.

EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in either a serious jeopardy to patient health, a serious impairment to bodily functions, or a serious dysfunction of any bodily organ or part. Although this definition is new to PIP, it is virtually identical to EMC definitions in Florida’s hospital licensing statutes for access to emergency care and treatment (Chapter 395) and Florida’s HMO statute (Chapter 641).

Change No. 3 – Follow-up Services

After the initial services, PIP covers follow-up services and care only if two more new requirements are met. First, there must be a referral by an authorized provider in connection with the initial treatment. (See No. 1 above). Second, follow-up services must be consistent with “underlying medical diagnosis rendered” in the initial service and care. Most Florida licensed providers and facilities may be reimbursed for follow-up services, although there are some limitations contained in the new law.

Change No. 4 – Shared Limits

The $2,500 limit for a non-emergency condition is shared among all medical services, including the initial services and examination, follow-up services, and diagnostic testing. The full $10,000 PIP limit is shared between medical benefits and disability benefits (lost wages).

Change No. 5 – Massage and Acupuncture Excluded

As the new law takes effect, PIP will no longer pay for massage therapy or acupuncture treatment, regardless of the person, entity, or licensee providing the service, and will not reimburse a licensed massage therapist or acupuncturist for services of any kind.

Change No. 6 – Chiropractic Limitations

Features discussed above will limit reimbursements for chiropractic treatment. There must be a referral for chiropractic services by an authorized provider in connection with the initial treatment, and chiropractic services must be consistent with the “underlying medical diagnosis rendered” in the initial service and care. A chiropractic physician is, however, an authorized provider for purposes of the initial services and referral. (See No. 1 above).

A chiropractic physician is not authorized to make an EMC determination. Thus, if the initial service and care is provided by the chiropractic physician, the patient may be limited to $2,500 for all medical services, unless the initial services also included an EMC determination by an authorized EMC provider. (See No. 2 above).

Change No. 7 – Clinics

The new law expands the list of entities that must be licensed as “clinics” by Florida’s Agency for Health Care Administration (AHCA) to be reimbursed under PIP. Clinics exempted from the licensing requirement include (a) entities owned by hospitals; (b) practices wholly owned by medical, osteopathic, and chiropractic physicians and dentists (and their respective families); and (c) clinical facilities affiliated with an accredited medical school at which training is provided for medical students, residents, or fellows.

Change No. 8 – Electronic Submission of Claims

This change attempts to bring PIP communications into the 21^st century. For electronic transmissions of invoices (statement of charges) and most other communications, the new law eliminates the requirement of mutual consent between the insurer and provider. As under current law, however, the communication must be made by secure electronic data transfer that is consistent with state and federal privacy and security laws. This change is effective December 1, 2012.

Change No. 9 – Provider May Correct Billing Errors

When an insurer rejects or reduces invoices for medical services, the provider may have another bite at the apple. When the reduction or rejection is due to an alleged error in the claim, the insurer is required to provide an itemized explanation. Upon receiving the explanation, the person making claim has 15 days to submit a revised claim.

Change No. 10 – Fee Schedule

The PIP statutory fee schedule gets a bit more complicated under the new law. Here are two examples: (1) The 200% Medicare Part B fee schedule will now apply to ambulatory surgical centers, clinical laboratories, and durable medical equipment; and (2) the Medicare fee schedule effective March 1 in any given year will be the applicable fee schedule for the remainder of the year until the subsequent update.

Caveats

There may be confusion come New Years Day 2013, due to differences of opinion on how to interpret sections of the new law. Some insurers and providers may be more aggressive, some more conservative. As is typical with a major legislative overhaul, there are legal questions that will remain in some doubt until the courts weigh in. 

For example, the new law does not state whether it applies prospectively to new and renewal policies only, or whether it applies retroactively to existing policies and accidents. If the new law applies prospectively only, changes will be phased in during 2013. To illustrate prospective application, if an insured’s policy was issued on August 1, 2012 and renews on February 1, 2013, for that insured the new law applies to auto accidents occurring on and after (not before) February 1, 2013. It may be up to the courts to resolve whether any of the January 1, 2013 changes apply retroactively and immediately on New Years Day, or are phased in prospectively as policies renew.

The PIP law changes in House Bill 119 (Chapter 2012-197 of Florida Laws) are more detailed and complex than presented in this summary. The above discussion is a limited and general description of the law and should not be relied on as legal advice.

This summary was prepared by Perry Cone and posted at TallyInsLaw.com.

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