The Florida legislature recently amended Florida Statute §627.736 (Florida Motor Vehicle No-Fault Law / PIP Statute). These changes become effective January 1, 2012.
- Subsection (1)(a) requires that the claimant receive initial services and care within 14 days after the motor vehicle accident in order to be eligible for benefits under the Florida Motor Vehicle No-Fault Law.
- The initial services and care must be provided by:
a) a medical doctor, osteopath, dentist or chiropractor; or
b) a hospital; or
c) a facility owned by a hospital; or
d) emergency medical service (EMS) personnel
- If a medical doctor, an osteopath, a dentist, a physician’s assistant, or advanced registered nurse practitioner determines that the claimant suffered from an emergency medical condition, reimbursement for all services and care is up to $10,000.00. If, however, a medical doctor, an osteopath, a dentist, a physicians’ assistant, or advanced registered nurse practitioner determines that the claimant did not suffer from an emergency medical condition, reimbursement for all services and care is limited to $2,500.00. Emergency medical condition is defined as “A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
a) Serious jeopardy to the patient’s health;
b) Serious impairment to bodily functions;
c) Serious dysfunction of any bodily organ or part.
**NOTE: While chiropractors are amongst those practitioners authorized to provide initial services, they are not amongst those practitioners authorized to determine that a claimant suffered from an emergency medical condition warranting the full $10,000.00 in medical benefits.
- Subsection (1)(a) also provides that massage and acupuncture are no longer reimbursable under the Florida Motor Vehicle No-Fault Law.
- Subsection (1)(a) provides the $5,000.00 in death benefits is over and above and in addition to the $10,000.00 medical and disability benefits.
- Subsection (4)(i) states, “If an insurer has a reasonable belief that a fraudulent insurance act, for the purposes of s. 626.989 or s. 817.234, has been committed, the insurer shall notify the claimant, in writing, within 30 days after submission of the claim that the claim is being investigated for suspected fraud. Beginning at the end of the initial 30-day period, the insurer has an additional 60 days to conduct its fraud investigation.”
- Subsection (4)(j) is new and requires the insurer to create and maintain a payout log, and, if litigation is commenced, to provide a copy of it to the insured within 30 days of the insured’s request.
- Durable medical equipment prosthetics/orthotics and supplies are not explicitly subject to the Medicare Part B fee schedule.
- The Medicare fee schedule is fixed as the one in effect on March 1 of each year and is the one to be used until March 1 of the following year notwithstanding any subsequent change made to the fee schedule or payment limitation.
- Insurers may use the Medicare coding policies and payment methodologies (OPPS, NCCI, etc.) used by the Center for Medicare and Medicaid Services, including applicable modifiers, to determine the appropriate amount of reimbursement for medical services, supplies, or care so long as the coding policy or payment methodology does not constitute a utilization limit.
- Subsection (6)(f) requires an insurer to notify the claimant of exhaustion of benefits either “upon request” or “within 15 days after the policy limits have been reached.”
- The insurance company’s right to take an Examinations Under Oath (EUO) is now included in the PIP statute and attendance is a condition precedent to receiving benefits (overruling Custer Medical and related cases on the EUO issue) The claimant’s failure to attend 2 defense medical examinations creates a ‘rebuttable presumption’ that the failure to attend was an ‘unreasonable’ failure.
- Under Fla. Stat. §627.736(8) attorney fees recovered under the Florida Motor Vehicle No-Fault Law must be calculated without a contingency risk multiplier.