| Topic |
Old Law |
New Law |
| PIP Clinics |
No Registration of clinics |
- Requires certain Clinics to register with the Department of Health and have a medical director. (See Flow Chart)
- Charges by facilities that were supposed to register, but who have not, are unenforceable.
- Criminal Penalty for operating as a clinic but not registered.
|
| Brokering |
Nothing Mentioned |
- Makes Brokering unlawful.
- MD's Osteopaths or Chiropractors who lease part time are not brokers.
- All other persons must be the 100% owner or 100% Lessee of the machinery.
- PIP clinics are not brokers so long as only their patients utilize the lease time.
|
| Medical necessity |
No definition |
- Adopts AMA definition of Medical Necessity
- requires that medical service be in accordance with generally accepted standards of medical practice, clinically appropriate in terms of site duration, frequency and extent; Not primarily for the convenience of the patient.
|
| Medical Benefits |
Reasonable expense for necessary medical, surgical, x ray, dental etc.
Permits compensation for faith healing |
Inserts the word medically before the word necessary
Faith Healing is still reimbursable but this provision can not be used to determine what medical benefits are reimbursable. |
| Explanations of Benefits |
Not required |
Must accompany any denied, reduced or omitted charges explaining the denial, reduction of omission. Must provide claim number and name of person to respond to. Insurer not limited by Explanation i.e. may come up with other defenses at time of trial. |
| Right to Contest Claim after 30 days (Perez) |
Perez (3rd DCA)disallows the use of evidence that was not in the possession of the carrier within 30 days to contest the claim. |
Permits after the fact defenses to reasonableness and necessity not limited by what was in their file within 30 days of receipt of the claim. |
| Interest |
10% on overdue claims calculated 30 days after the date received. i.e. if one day late, one day interest |
Raises the interest rate to the rate established by the comptroller or the rate in the insurance contract, whichever is greater and calculates interest from the date the bill was received by the insurance carrier. If one day late, 31 days of interest. |
| Medical Payments |
Med Pay tied to PIP to pay the 20% not reimbursed by PIP |
Eliminated. Med Pay may pay for benefits only after PIP is exhausted. (Check contract) |
| Charges for Treatment |
Provides for reimbursement of products and accommodations |
Eliminates products and accommodations and inserts supplies instead. |
| Limitations of charges for MRIs and other testing |
|
- Adds spinal ultrasounds, extremity ultrasounds, video fluoroscopy and surface electromyography to the workers comp fee schedule.
- Nerve Conduction studies if done in conjunction with Needle EMGs if done by a Physician or Health Care provider certified by the appropriate Board can be billed at 200% of Medicare for your area.
- All other Nerve Conduction Velocities are reimbursed at workers comp fee schedule rates.
- MRI services prior to November 1, 2001 200% of Medicare. After November 1, 2001 200% of Medicare if the MRI facility is certified by the American Academy of Radiology or Joint Commission on Accreditation of Healthcare facilities. 175% of Medicare for all other facilities.
|
| 30 day billing requirement |
30 days from date of service
60 days if you file initiation of treatment.
No escape clause for wrong information given by insured. |
35 days from the date of service
75 days if you file initiation of treatment.
35 days from receipt of correct information for insurer to submit bills provided you submit:
- documentary proof of incorrect information and a) denial from incorrect insurer or b) proof of mailing to incorrect insurer.
|
| Physician's Report of Injury |
Permits insurers to request report detailing the history, condition, treatment dates and cost of treatment +Sworn statement that services are reasonable and related
Allows insurers to receive copies of records
Request must be made within 20 days of receipt of bill. |
Adds to these an explanation as to why certain charges were reasonable and necessary.
Adds that the provider is not limited to the explanation at trial; i.e. may add additional information
Makes it a bad faith practice for insurers to request information about the reasonableness or necessity of charges without a reasonable basis for doing so.
Extends to 30 days from receipt of bill. |
| Physician's report of injury (cont) |
Insurer must pay the charges for the report
Must pay that part of the charges not in dispute and the remainder within 10 days after receipt of the explanation. |
|
| IME's |
Requires that an insurer must have a report from a physician licensed under the same chapter before cutting off treatment. |
Now requires a valid report.
- must be prepared and signed by the physician performing the examination or reviewing the records.
- must be supported by the examination and review of records and if modified can only be modified by physician
- physician must be in active practice unless physically disabled.
- active practice means during the 3 years preceding examination IME was in active clinical practice or teaching at an accredited school.
|
| Pre Suit Demand Letter |
None |
Prior to filing suit a demand for payment must be made for;
overdue interest only and where the insurer has unintentionally omitted a date(s) of service.
Not required where insurer denies or reduces a bill
Notice must be sent by certified mail and identify the named insured and attach the HCFA forms that have not been paid.
Must be sent to the person on the explanation of benefits or someone designated by the insurer or the person listed under 624.422
Once received insurer has 7 business days to pay overdue claim plus 10% penalty and interest.
Bad faith to not pay until notice
Statute tolled for 15 days |
| Civil Action for Insurance Fraud |
None |
Insurance company can sue civilly for anyone who pleads no contest or pleads guilty to violation of
- Patient Brokering
- Insurance Fraud, including solicitation
- kickbacks
Adjudication of guilt not required
Can recover attorneys fees, compensatory and punitive damages |
