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Did the PIP Insurance Company pay the bills correctly?

Did the PIP Insurance Company pay the bills correctly?

Recently, in the case of Kingsway Amigo Insurance Company v. Ocean Health a/a/o Belizaire Gomez, the Fourth District Court of Appeals ruled that a PIP insurer may not elect to use Medicare Part B fee schedules set forth in section 627.736(5)(a)(2) when the subject policy specifies that the PIP insurer will pay 80% of medically necessary expenses.  Additionally, the Court held that the incorporation of PIP statute into policy did not give the insurer the unilateral right to ignore the only payment methodology referenced in the policy.  The importance of this case can not be disregarded by any health care provider who has submitted medical bills to PIP carriers for reimbursement, only to receive benefits provided via the very low paying Medicare Part B fee or workers’ compensation fee schedule.  In my experience litigating this identical issue ever since insurers starting paying pursuant to the Medicare Part B fee schedule on January 1, 2008, I often see reimbursement paid to health care providers at about 10% or less of the amount billed.

After the Florida PIP statute was reenacted on January 1, 2008, there were some amendments made to differentiate it from the prior PIP statute.  Perhaps no change was more controversial than the reimbursement methodology afforded to PIP insurers.  The statute reads that reimbursement shall be paid at 80% of reasonable medical expenses.  However, the reenacted statute also states that insurers may limit payment to those rates found in the Medicare Part B fee or workers’ compensation fee schedule.  Despite the changes in the statute, most insurers did not bother to update their policies to reflect their ability to pay on the lower-paying fee schedules.  However, most insurers paid pursuant to the fee schedules anyway, despite using older policies that explicitly state payment shall be pursuant to 80% of reasonable medical expenses.

In all my experience litigating on this issues, most insurers try to defend their decision to pay per the fee schedules by stating that they have some language in their policies stating that they will pay “in accordance with the Florida Motor Vehicle No-Fault Law, as amended.”  However, in the same policy, it will state that they will pay at 80% of reasonable rates for medical services.  This creates ambiguity in the policy, and when there is ambiguity in a policy, courts construe it against the drafter (in this case, the insurance companies).  Thus, insurers must pay as their policy dictates – pursuant to 80% of reasonable expenses.

If you are a health care provider who has received payments via the Medicare Part B fee or workers’ compensation fee schedule, and this reimbursement amount was less than the amount you billed for medical services you have rendered, please contact our office to discuss the opportunity of having our attorneys seek additional payment for your services.  For example, if you submitted a bill to a PIP insurer for $2,250.00, and received a fee schedule payment of $275.00, our team will pursue litigation in an effort to get you the difference of 80% of the $2,250.00 that you had billed ($1,800.00), and the $275.00 the PIP insurers have paid, for a total amount of $1,525.00 in this example.  We can go all the way back to January 1, 2008, when most PIP insurers started to unlawfully pay pursuant to the fee schedules when their policies explicitly stated that they would reimburse at 80% of reasonable medical expenses.

If you have any questions about this case or any other PIP cases, please do not hesitate to contact Attorneys Lyle B. Masnikoff or Leandro Carvahlo at 1-561-598-7120.


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