South Florida Hospital News
Friday October 23, 2020

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July 2012 - Volume 9 - Issue 1


Medical Providers Could Be Stiffed Millions of Dollars by Glitch in New PIP Reform

The massive Personal Injury Protection reform heralded by the governor as one of the 2012 session’s major accomplishments also has a major problem. A gaping hole in this so-called “triumphant” legislation technically allows insurers to skip out on paying health care providers for treating accident victims for real injuries.
This is the much-ballyhooed law, which took effect in part on July 1, that was supposedly designed to target and root out fraud. And yet, it’s legitimate medical providers treating legitimate, verifiable injuries who could be out millions of dollars based on a reading of the law that troubles even state officials.
In their hurry to placate the insurance industry and hand Gov. Rick Scott one of his top priority items, lawmakers left a gap in coverage that could end up shorting the health care industry millions in earned income. The highly touted HB 119 contains a six-month eligibility gap that insiders say could provide insurers cover to avoid paying certain medical providers, such as doctors, chiropractors, medical schools and dentists. Under one part of the law, these professionals lose their eligibility on July 1, while another part of the act restores their eligibility on Jan. 1, 2013.
The state's Agency for Health Care Administration is so troubled by the potential for this glitch to give insurers technical legal standing to stiff medical professionals for doing their job that it is scrambling to find a fix before the law takes effect next month.  
In early May, AHCA released a three-page memo saying it intended to eliminate the loophole. In the memo, AHCA’s general counsel, Stuart Williams, said he could foresee how the eligibility gap “would place the agency in a conundrum.” But he said AHCA’s reading of the legislation is that the health care professionals in question are qualified under the law without a hiccup.
“The agency believes that the (law) applies the same effective date of January 1, 2013 to both the new licensure requirement” and the exemption, Williams said in the memo.
AHCA’s efforts are a welcome attempt to settle a troubling snafu. But they very well may not be enough. Legal experts have gone on record in a number of media reports to say that an agency memo may help the courts decide the intent of the law, but it will not necessarily prevent insurers from using the apparent six-month gap to deny legitimate payment, prompting a legal battle to recoup the earnings.
It’s very likely then that we will see a flurry of court filings in the weeks and months ahead, as insurers test the eligibility gap and medical providers file suit to get the money they deserve. So much for reform settling the PIP landscape and maintaining fairness in the world of vehicle accident coverage.
In fact, this is just one aspect of PIP reform that promises to tie the state’s courts up for a long while. The law comes with lots of hits to consumers' rights: restrictions that require patients to seek initial diagnosis of their injuries within 14 days of an accident; limits on who can diagnose their injuries; bans on seeking coverage for massage and acupuncture therapies; and limitations that allow motorists to recoup only $2,500 of their $10,000 mandated coverage unless they sustain injuries that require "emergency" treatment. These sweeping changes leave lots of unanswered constitutionality questions that only the courts will be able to sort out.
Meanwhile, one Miami personal injury attorney has already announced that she's planning to sue to have the law overturned as unconstitutional, arguing that it undermines a 1974 Florida Supreme Court ruling supporting PIP's careful balance of motorists' reduced right to sue with the expectation of swift payment of their medical claims.
So PIP reform may now be the law of the land in Florida, but it will take some time before we know how it really shakes out.
C. Glen Ged is CEO of Ellis, Ged & Bodden, a Boca Raton-based law firm that specializes in collecting delayed or wrongly denied PIP insurance claims for healthcare providers. He can be reached at, 1-888-EGB-FIRM (342-3476) or (561) 995-1966.
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