Top 5 PIP Issues For Medical Providers To Be Aware Of

MEDICARE CODING ISSUES

such as:

National Correct Coding Initiative (NCCI) and Multiple Procedure Payment Reduction (MPPR), failure to pay due to utilization limitations

1. If the insurer states they did not pay a code or reduced a code for the above reasons, call us or send us your EOBS/files.
2. This coding information is found on the Explanation of Benefits.

EMC DENIALS

1. Some insurers are denying payment even if a practice sends an Emergency Medical Condition Report. They deny utilizing a Peer review which is NOT PERMITTED.
2. Insurers hire humans to work for them. It is human nature to assume you have not received documents or to omit a document in your file. If an EMC was sent with the claim and the insurer requests the same again, a suit may be immediately filed!

PROOF OF MAILING

1. Claims have been sent but the insurer alleges they did not receive a particular date of service.  If the insurer re-requests the bills, you do not have to do double work.  The insurer’s delinquence is actionable.
2. If we litigate on behalf of the practice, you will receive interest payments plus the money you’re owed.  To prove the claim was mailed in a timely fashion, always keep a copy (re-printed is ok) of the actual HICFA and an envelope or tracking number proving the bills were initially mailed.

PATIENT GIVES INCORRECT INSURANCE INFORMATION AND YOU RE-SUBMIT THE BILLS AFTER DETERMINING THE CORRECT INSURANCE CARRIER

1. Do not fret if this situation occurs. Providers have a full 35 days to send claims to the correct carrier.
2. Example: Patient A State Farm is their PIP insurer. Practice sends claims to State Farm.  State Farm responds stating Patient A is not covered by State Farm and in fact, is insured by Progressive.
   1. You now have 35 days from the date you received the correct information to re-submit the bills.  Include a copy of the means in which the correct information was received as proof of the date received.

*HELPFUL NOTE: USAA alleges you have 15 days from the date you received the correct information. That is untrue. Do not be tricked into the insurer’s manufactured timetables.

FEE SCHEDULE LITIGATION

1. Some insurers’ policies do not elect the fee schedule in a clear and unambiguous manner.  In light of recent District Court of Appeals decisions, insurers must make both the insured and medical provider aware of the reimbursement choice; whether they pay 80% of the charges OR per the Medicare Fee Schedule.
2. It is our goal at LaBovick Law Group to fight the good fight and ensure maximum reimbursement.
3. State Farm’s pre-2012 policy, Allstate’s pre-2012 policy, MGA’s policies, and a slew of other insurers’ policies should be litigated because they are not compliant in the manner in which they reimburse for provider services!!!!!!!!