PIP Billing For Unlisted Services: A Guide For Medical Providers

As medical providers in Florida strive to comply with the complex landscape of billing Personal Injury Protection (PIP) insurance, the question of how much to bill for services lacking established reimburse- ment amounts under the Medicare Part or Workers’ Compensation fee schedules looms large. The intricacies of this issue are particularly relevant following a recent court decision that shed light on insurance company obligations to pay for unlisted services.

PIP insurance is a crucial component of Florida’s no-fault insurance system, designed to cover medical expenses for individuals injured in automobile acci- dents, regardless of fault. According to Section 627.736. Florida Statutes, PIP insurers are expected to reim- burse medical providers for “all reasonable expenses” incurred during treatment. This broad mandate raises significant questions when the services rendered do not align with pre-established reimbursement schedules.

Florida law stipulates that when available, reim- bursement amounts should adhere to existing fee schedules set forth by Medicare or Workers’ Compensation. However, the reality is that some medi- cal services-especially specialized treatments do not have corresponding amounts listed in these schedules.

In August 2023, the Fourth District Court of Appeal Issued a pivotal ruling in the consolidated cases of Safeco Insurance Company of illinois v. MD Now Medical Centers, Inc., LM General Insurance Company. MD Now Medical Centers, Inc. a/a/o Lisa Lugo, and Liberty Mutual Insurance Company v. MD Now Medical Centers, Inc. These consolidated appeals raised important concerns. regarding the obligations of PIP insurers to reimburse medical services without established reimbursement amounts under Medicare or Workers’ Compensation.

The Court reiterated that while PIP reimburse ment should reference these established fee schedules, when possible, it is not strictly bound to them. The ruling established that PIP insurers must have a methodology for determining reimbursement for an unscheduled service that is done by comparing the billed code(s) with clinically similar codes found in the Current Procedural Terminology (CPT) Manual or the Healthcare Common Procedure Coding System (HCPCS) Manual. This ruling is particularly significant because it clarifies that providers may seek reimbursement of their charges even if the charges do not have an established reimbursement amount.

Given the court’s affirmation of reimbursement for unlisted services, medical providers must implement comprehensive strategies for billing PIP insurance when it comes to these unlisted services. The basis for this strategy should involve:

1. Assessment of Market Rates: Providers should research and document the standard fees forsimi- lar services within their region. Using industry benchmarks will help establish a fair and justifi- able billing rate.
2. Documentation of Medical Necessity: Each service should be accompanied by thorough documentation demonstrating its necessity, Clear medical records can substantiate charges and enhance the provider’s position during potential disputes with insurance companies.
3. Billing Procedures: Adopt transparent billing practices by breaking down services into detailed line items. This approach not only helps justify the total charges but also provides clarity for both the insurer and the patient.
4. Engagement with Insurers: Providers should be proactive in communicating with PIP insurers regarding their billing practices, especially when services do not fit neatly into existing reimbursement structures. Open dialogue can help prevent disputes and promote timely payment.

As Florida’s medical providers face the challenges associated with PIP billing for services without predetermined reimbursement amounts, the recent 4th DCA ruling provides ammunition for medical providers who are seeking reimbursement for unlisted services. By emphasizing reasonable billing practices, thoroughly documenting services, and being prepared to justify charges, providers will increase the likelihood of PIP reimbursement for these unlisted services. This not only ensures they receive fair compensation but also enhances the overall integrity of the healthcare system in Florida.