PIP Medical Benefits – Getting The Bills Paid
Physicians and their office staffs are often frustrated by the Personal Injury Protection (PIP) system. You may want to pass this article on to the head of your billing office.
All auto liability policies in Oregon are required to provide PIP (no fault) coverage for prompt payment of reasonable and necessary medical expenses resulting from an accident.
What is “reasonable and necessary”? The law provides:
“Expenses of medical, hospital, dental, surgical, ambulance and prosthetic services shall be presumed to be reasonable and necessary unless the provider is given Notice of Denial of the charges not more than 60 calendar days after the insurer receives from the provider notice of the claim for the services.”
In other words, the insurance company must pay you within 60 days after receiving your bill or notify you that they are denying.
However, during the first 50 calendar days after receiving your bill (claim), the insurer may raise questions regarding the claim. If so, you (the medical provider) must answer in writing 10 business days or the 60-day period will be extended. It is therefore important that any requests for information are answered promptly.
PIP coverage is not subject to regulations (such as found in managed care programs/HMO’s) concerning which doctor an injured patient may go to. That is, there is no need to go through a “primary care physician” (or “gatekeeper”). Also, there are no rules or guidelines preventing the treating doctor from deciding what care is reasonable and necessary to treat the accident injuries.
What is reasonable in the amount of payment for medical services is decided by a community standard. PIP almost always pays in full, without the reductions usually applied by such insurers as Blue Cross Blue Shield. A PIP insurer may try to pay less, but our experience has been that, if challenged, full payment is usually ordered.
Your billing office may not be certain whether an injured patient is covered by PIP; and, if so, which insurance company gets billed. Here are some guidelines.
First general rule: “PIP follows the car.” If the car is insured, PIP covers all occupants no matter who was at fault. So, in most cases you will bill the insurer for the car your patient was in when injured.
But PIP can be available from several sources and is cumulative.
1. John is driving or riding in Mary’s car, insured by Farmer’s. Farmer’s PIP covers John’s injuries. John’s car insurance is Allstate. If the Farmer’s PIP coverage amount is exceeded, Allstate kicks in.
But if Mary has no car insurance, John’s PIP coverage (Allstate) will kick in immediately.
2. Household rule: Trevor is injured as a passenger in an uninsured vehicle of one of his teenage friends. Trevor has no car or insurance, but his parents have a car insured by State Farm. Trevor’s injuries are covered by his parents’ PIP, since he is a member of their household, even though their insurance did not cover the car. The “Member of the Household” rule in most policies covers only household members related to the policy-holder by blood or marriage.
3. If Trevor is walking or riding his bike and is injured by someone driving a car, his injuries will also be covered by his parents’ PIP. However, if Trevor is living in his own apartment (not his parents’ household) and has no car or health insurance nor a welfare medical card, then the PIP on the car which hit him will pay for his accident-related medical expenses.
4. If Trevor is still living at home and buys his own car, but does not insure it, his parents’ PIP coverage will probably not cover injuries he suffers in his car. Insurance companies are not required to provide PIP coverage to two cars in the same household for the price of one. Therefore, most policies will exclude uninsured vehicles in the same household.
5. Motorcycles: Insurance companies are not required to provide PIP on motorcycle policies. Also, many auto policies exclude PIP coverage for motorcycle accidents. For example, Bill has insurance on both his motorcycle and his car and gets hurt while riding his motorcycle. His car policy probably excludes coverage for accidents on a motorcycle, so Bill must look to his health carrier, if he has one, to pay his medical bills.
The staff of Black, Chapman, Petersen and Stevens is available for free consultation regarding PIP coverage questions. Please call and ask for Roberta Kent or Julia Linebarger-Taylor.
This article was prepared by Dennis Black