How do medical bills get paid in a car accident case?

At Drucker Law Offices, I get a lot of questions about the cost of medical treatment when my clients are in car accidents.  People see explanations of benefits showing “allowable charges” from their car insurance and they are unclear as to how much treatment they are entitled to under PIP’s $10,000.00 coverage.  The accident attorney in Boca (accident lawyer in Miami, personal injury lawyer in Miami Gardens, accident attorney in North Miami Beach, injury lawyer in North Bay Village, injury attorney in Kendall, injury lawyer in Downtown Miami, accident lawyer in Aventura) will try to answer some common questions about the cost of medical treatment following a car accident. 

Generally, in a car accident case, medical bills are paid through the appropriate automobile insurance carrier.  As discussed in the last blog entry, in a Florida car accident, your own car insurance generally pays your medical bills, regardless of fault and regardless of whether you are in your car, another car or even if you are hit by a motor vehicle as a pedestrian or on a bicycle.  If you do not own a car, then if you live with a relative that owns a car, then that relative’s automobile insurance, regardless of fault and regardless of whether you were in that relative’s car or even if you were hit by a car while on a bicycle or as a pedestrian.  If you do not own a car nor live with a relative that owns a car, then you generally would qualify for PIP benefits through the car that you were in or from the car that hits you if you are on a bicycle or on foot.

The statute pertaining to the cost for treatment under Florida’s No-fault PIP laws is discussed in 627.736(5), a copy of that statute is pasted below.  Understanding the history of the bill might prove somewhat insightful.  Prior to January 1, 2008, there were no PIP fee schedules for doctors, which basically means that the doctors and hospitals could charge “usual and customary” charges.  These charges had to be reasonable and necessary and also had to be causally related to the accident but otherwise there were no fixed charges for most medical treatment (prior to 2008, a fee schedule for MRIs were already part of the statute. 

Under the current laws (post January 1, 2008), hospital charges are allowed to be at 75 percent of the usual and customary charges and then they are paid at 80 percent.  Thus, generally, if a hospital charges are $1,000.00 and the bill is submitted to an automobile PIP carrier, the bill is reduced to $750.00 and paid at 80 percent or $600.00.  Under the statute, the hospital is not allowed to charge the patient for the difference, i.e. the $250 reduction is a write off and thus after the payment of $600.00, the balance owed would be $150.00 not $400.00.  Ancillary hospital bills (emergency room physician, hospital radiology and ambulance charges) are allowed under the statute at usual and customary and thus there generally would not be a reduction for those bills. 

After the hospital, if the injured person goes to a private physician (chiropractor, primary care physician, orthopedist, neurologist, medical doctor, etc.), the charges are limited to 200 percent of the medicare fee schedule and then paid at 80 percent.  Thus if an initial visit to the doctor is charged at $500.00 (this is the doctor’s usual and customary charge), the PIP carrier would review the fee schedule and if the medicare fee schedule pays $150.00 for that particular coded visit, then the PIP carrier is allowed to reduce that charge to $300.00 (double the medicare of $150.00) and it gets paid at 80 percent or $240.00.  The balance owed would be $60.00 and not $260.00 as the $200 reduction per the fee schedule is generally not allowed to be charged against the patient per the statute.  If the PIP benefits are exhausted, i.e. the $10,000.00 has already been paid back, then the fee schedule no longer applies and the whole charge is due and owing. 

While generally it takes $12,500.00 to exhaust PIP benefits (presuming a no deductible, $10,000.00 PIP policy paying at 80 percent), you can see that it is not so easy to figure out when PIP benefits have exhausted in a case.  Many automobile insurance companies will send explanation of benefits to their insureds, and from this the patient can see approximately where there benefits are at certain points of treatment but again it is not so easy as the doctors do not necessarily bill right after each treatment.  There are even companies that will allow people with online access to check their available PIP benefits but again with delayed billing, this is not necessary updated with all billing to that moment. 

Every case is different and must be judged on its merits. It is a good start to get a free consultation regarding an accident case in case this happens to you. The advice contained in this blog is intended to be of general matter and not as to a specific situation, so please call a licensed Florida attorney, like the lawyer at Drucker Law Offices, to determine if and how Florida law applies to your case.

It is difficult to analyze available PIP benefits in a case but at Drucker Law Offices, the accident attorney from Boca (injury lawyer in Delray Beach, personal accident attorney in Northlake, injury attorney in Loxahatchee, injury lawyer in Royal Palm Beach, accident attorney in Wellington, accident lawyer in Boynton Beach, personal injury attorney in Lake Worth, injury lawyer in Lake Park, injury attorney in West Palm Beach, accident attorney in the Acreage, accident lawyer in Palm Beach) helps client with these issues and offers a free consultation to people that have been involved in any sort of accident where they believe someone else caused the accident.  Please call with any questions at the principal office in Boca Raton 561-483-9199, satellite office in Miami 305-981-1561, satellite office in Coral Springs 954-755-2120, satellite office in Boynton Beach 561-265-1976 or the satellite office in West Palm Beach 561-686-7070.

(5)  CHARGES FOR TREATMENT OF INJURED PERSONS.–

(a)  Any physician, hospital, clinic, or other person or institution lawfully rendering treatment to an injured person for a bodily injury covered by personal injury protection insurance may charge the insurer and injured party only a reasonable amount pursuant to this section for the services and supplies rendered, and the insurer providing such coverage may pay for such charges directly to such person or institution lawfully rendering such treatment, if the insured receiving such treatment or his or her guardian has countersigned the properly completed invoice, bill, or claim form approved by the office upon which such charges are to be paid for as having actually been rendered, to the best knowledge of the insured or his or her guardian. In no event, however, may such a charge be in excess of the amount the person or institution customarily charges for like services or supplies. With respect to a determination of whether a charge for a particular service, treatment, or otherwise is reasonable, consideration may be given to evidence of usual and customary charges and payments accepted by the provider involved in the dispute, and reimbursement levels in the community and various federal and state medical fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service, treatment, or supply.

(b)1.  An insurer or insured is not required to pay a claim or charges:

a.  Made by a broker or by a person making a claim on behalf of a broker;

b.  For any service or treatment that was not lawful at the time rendered;

c.  To any person who knowingly submits a false or misleading statement relating to the claim or charges;

d.  With respect to a bill or statement that does not substantially meet the applicable requirements of paragraph (d);

e.  For any treatment or service that is upcoded, or that is unbundled when such treatment or services should be bundled, in accordance with paragraph (d). To facilitate prompt payment of lawful services, an insurer may change codes that it determines to have been improperly or incorrectly upcoded or unbundled, and may make payment based on the changed codes, without affecting the right of the provider to dispute the change by the insurer, provided that before doing so, the insurer must contact the health care provider and discuss the reasons for the insurer’s change and the health care provider’s reason for the coding, or make a reasonable good faith effort to do so, as documented in the insurer’s file; and

f.  For medical services or treatment billed by a physician and not provided in a hospital unless such services are rendered by the physician or are incident to his or her professional services and are included on the physician’s bill, including documentation verifying that the physician is responsible for the medical services that were rendered and billed.

2.  Charges for medically necessary cephalic thermograms, peripheral thermograms, spinal ultrasounds, extremity ultrasounds, video fluoroscopy, and surface electromyography shall not exceed the maximum reimbursement allowance for such procedures as set forth in the applicable fee schedule or other payment methodology established pursuant to s. 440.13.

3.  Allowable amounts that may be charged to a personal injury protection insurance insurer and insured for medically necessary nerve conduction testing when done in conjunction with a needle electromyography procedure and both are performed and billed solely by a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 who is also certified by the American Board of Electrodiagnostic Medicine or by a board recognized by the American Board of Medical Specialties or the American Osteopathic Association or who holds diplomate status with the American Chiropractic Neurology Board or its predecessors shall not exceed 200 percent of the allowable amount under the participating physician fee schedule of Medicare Part B for year 2001, for the area in which the treatment was rendered, adjusted annually on August 1 to reflect the prior calendar year’s changes in the annual Medical Care Item of the Consumer Price Index for All Urban Consumers in the South Region as determined by the Bureau of Labor Statistics of the United States Department of Labor.

4.  Allowable amounts that may be charged to a personal injury protection insurance insurer and insured for medically necessary nerve conduction testing that does not meet the requirements of subparagraph 3. shall not exceed the applicable fee schedule or other payment methodology established pursuant to s. 440.13.

5.  Effective upon this act becoming a law and before November 1, 2001, allowable amounts that may be charged to a personal injury protection insurance insurer and insured for magnetic resonance imaging services shall not exceed 200 percent of the allowable amount under Medicare Part B for year 2001, for the area in which the treatment was rendered. Beginning November 1, 2001, allowable amounts that may be charged to a personal injury protection insurance insurer and insured for magnetic resonance imaging services shall not exceed 175 percent of the allowable amount under the participating physician fee schedule of Medicare Part B for year 2001, for the area in which the treatment was rendered, adjusted annually on August 1 to reflect the prior calendar year’s changes in the annual Medical Care Item of the Consumer Price Index for All Urban Consumers in the South Region as determined by the Bureau of Labor Statistics of the United States Department of Labor for the 12-month period ending June 30 of that year, except that allowable amounts that may be charged to a personal injury protection insurance insurer and insured for magnetic resonance imaging services provided in facilities accredited by the Accreditation Association for Ambulatory Health Care, the American College of Radiology, or the Joint Commission on Accreditation of Healthcare Organizations shall not exceed 200 percent of the allowable amount under the participating physician fee schedule of Medicare Part B for year 2001, for the area in which the treatment was rendered, adjusted annually on August 1 to reflect the prior calendar year’s changes in the annual Medical Care Item of the Consumer Price Index for All Urban Consumers in the South Region as determined by the Bureau of Labor Statistics of the United States Department of Labor for the 12-month period ending June 30 of that year. This paragraph does not apply to charges for magnetic resonance imaging services and nerve conduction testing for inpatients and emergency services and care as defined in chapter 395 rendered by facilities licensed under chapter 395.

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