One issue that can arise in PIP claims is a denial based on an allegation that certain billed services were not actually rendered. This often develops after the insurance company conducts an Examination Under Oath (EUO)of its insured. During the EUO, the insured may be asked to identify or describe the specific services performed by […]
CPT Code 98960 is a patient self-management education and training code commonly billed for individualized instruction provided by a qualified nonphysician healthcare professional. In Florida PIP litigation, insurers have frequently argued that CPT 98960 is not reimbursable under the Medicare Part B Participating Physicians Fee Schedule because Medicare labels the code with a “Status B” […]
An EOB (Explanation of Benefits) is the document an insurance company issues after reviewing a medical bill. It explains: In simple terms: An EOB is the insurer’s justification for how it handled a medical bill. Why EOBs Matter in Florida PIP Under Florida’s PIP statute (§ 627.736), insurers must: That explanation is typically provided through […]
OPPS stands for Outpatient Prospective Payment System. It is a Medicare reimbursement methodology used to pay for hospital outpatient services. Instead of paying based strictly on a physician’s fee schedule, OPPS assigns services to payment classifications and reimburses based on predetermined rates. In simple terms: OPPS is one of Medicare’s official payment systems — and […]
The 30-Day Billing Rule Under Florida PIP Florida’s Personal Injury Protection statute, section 627.736(5)(b), Florida Statutes (1999), imposed a strict 30-day billing requirement for medical providers submitting PIP claims. The statute states that a provider’s statement of charges “may not include” charges for treatment rendered more than 30 days before the postmark date, and the […]
Florida’s Personal Injury Protection statute, section 627.736(1)(a), Florida Statutes, requires insurers to pay eighty percent of all reasonable expenses for medically necessary medical benefits arising from a motor vehicle accident, and Florida courts have interpreted this language to include reasonable transportation expenses incurred to obtain that medical care. The Florida Supreme Court squarely addressed this […]
The Short Answer Under Florida law, the PIP deductible must be subtracted from the total medical bill first, before the insurance company applies any fee schedule or reimbursement limitation. The Florida Supreme Court has clearly ruled on this issue. Why This Issue Comes Up In many PIP claims, insurers try to: This approach results in […]
