A local neurosurgeon recently told one of our clients, "40% of the work I do is low pay or no pay."

Fortunately, there is one last bastion of "unmanaged" care: PIP. PIP is one of the last places where your fees are not managed - a "fee for service" program written into the law.

Yes, the Personal Injury Protection law still requires insurers to pay for the reasonable and necessary expenses of treating your patient's automobile accident injuries. These reasonable and necessary expenses are set by you, the physician.

The law requires insurers to pay benefits "promptly" after a proof of loss has been submitted. While of course the insurer can contest both the need for and the cost of treatment, the law further provides that medical expenses are presumed to be reasonable and necessary, unless the insurer notifies you of its denial within 60 days after the insurer receives your bill. (This time period may be extended if you do not answer within 10 days any questions the insurer may ask you within 50 days after receiving your bill.)

Every private passenger motor vehicle liability policy issued in Oregon is required to provide PIP benefits. So, if your patient was injured as a passenger or driver in an insured motor vehicle or the patient has his or her own private auto policy, treatment for your patient's injuries is covered. Also covered are family members in the household of a person with an insured vehicle.

So, your injured patient's PIP insurance may be the best money out there for paying for your treatment. PIP and working with a personal injury law firm who will protect your fees with a lien are your best bet for getting what you have billed paid in full. We are aware that not all personal injury law offices are aggressive or thorough in making sure treating doctors are paid fairly for their work.

At our office, the staff spends a large percentage of its time monitoring our client's bills to try to make sure they are paid either by the appropriate insurance plan or out of settlement proceeds. This is what your patients want and we view it as part of good customer service. Also, we have consulted at no charge with medical providers and their office staffs to assist them in understanding the legal and practical intricacies of this aspect of medical billing in order to help ensure that personal injury and workers' compensation billings are correctly paid.

Physicians, and their professional organizations, would be wise to keep a vigilant eye out for threats to the PIP law. In at least one other state (Colorado), the PIP equivalent has been subject to the types of restrictions now used in Workers' Compensation law in Oregon: managed care organizations (MCO's) and Preferred Provider Organizations (PPO's). As you well know, such programs for "managing" medical care have ways of whittling down your fees and second-guessing your treatment.

For example, PIP laws may be changed to impose payment schedules to replace your reasonable and necessary fees.

It has come to our attention that one way MCO/PPO programs in the Oregon Workers' Compensation system have impacted medical care has been efforts by some workers' compensation carriers to exclude doctors who do discograms from its MCO/PPO panels. While all physicians may not be in a position to use them, or may not choose to use them, discograms do objectively document and diagnose injury. It appears that such verification is viewed as a step toward treatment entailing expenses that the insurers would prefer to avoid, if at all possible.

In this and other ways, managed care programs can be and are used to discourage or exclude providers and approaches designed to diagnose and treat the full extent of a patient's injuries. What you consider reasonable and necessary to treat your patient may be subject to limits, schedules and preferences allowed by the legislature and imposed by those paying the bills.

Therefore, we encourage you to be alert to any proposed legislation and pro-active in protecting PIP from changes which may affect your authority to decide, and receive fair compensation for, whatever may be reasonable and necessary to treat your injured patients.

This article was prepared by Dennis H. Black