QuestionWE HAVE A PATIENT WHOSE PIP BENEFITS WERE DENIED DUE TO IME CUTT OFF/MAX. MEDICAL IMPROVEMENT REACHED, WE USUALLY FILE FOR ARBITRATION BUT BEING THAT THIS PATIENT WAITED 12-14 MONTHS AFTER BEING CUTT OFF TO COME BACK FOR TREATMENT, WE HAVE NOW STARTED BILLING HIS HEALTH INS. I MEAN FOR HOW LONG WILL AN MVA BE MVA RELATED. IS IT LEGAL TO BILL THE HEALTH INS. CARRIER AFTER BENEFITS WERE TERMINATED? THANK YOU FOR YOUR HELP.
AnswerHi Betty,
I am guessing that your boss is a chiropractor who is now being asked to resume treatments. Your question has some important implications, so let’s work together to examine all facets of these issues. As you will see, what your doctor does now, in relation to rebutting the IME, or just in making the etiology clear, will have a tremendous impact upon your patient’s third party claim (i.e. versus the tortfeasor).
First, in answer to your direct question, YES, it is legal to bill the health insurer since the auto insurer will no longer pay, having cut off the PIP due to the Insurance Medical Examination (IME).
So that takes care of billing. But make sure that your doctor does not try to get too clever and avoid mention of the MVA in her notes for fear of getting the billing denied. She MUST CONTINUE TO RELATE THE INJURY TO THE MVA (assuming, of course, that the clinical history shows no intervening causation).
FIGHT FOR THE PATIENT. Do NOT let your doctor be bowed or intimidated by the IME. Those doctors are mainly prostitutes for the insurance industry, and I will bet that the doctor who signed off on terminating benefits makes a huge percentage of his income screwing over innocent victims on behalf of the insurance industry.
Hence, your doctor should get a copy of the IME, and attack it in her notes. Mention that she has seen it, but that she disagrees, and particularly she finds that this latest pain brought on by normal work and living is caused by the trauma of the auto accident. As for the basis of making such an opinion, let your doctor know that she has only to meet the civil lawsuit standard of proof: that a thing is more likely than not true.
In other words, she does not have to believe the etiology beyond a reasonable doubt. Nor does she need to cite clear, cogent, and convincing evidence in order to tie this relapse to the accident. All she needs to believe is that it is more likely than not true that this need to return for treatments is a relapse of the condition that was first caused by the trauma suffered in the auto accident.
OK, Betty, now we are going to get really weird. Have you thought of submitting the billing to the PIP? That is what I would like for my client’s doctor to do. Of course we really all know that it will be denied, but why not try? In direct answer to your question, a layoff of that many months is not fatal to the etiology connection, depending upon the clinical history since the patient had to quit.
One issue will be the length of the PIP coverage. Standard policies are one year and three years. This sounds like a three year coverage. So it likely is still in effect, and the only issues will be proof of connection to the accident, and overcoming the IME.
Here are reasons why you should submit the new billings to the PIP. First, it gives your doctor a chance to blast the IME. She can pick out that part that says further treatments are not required, and argue that the normal living conditions did cause exacerbation of the patient’s condition, and hence, further treatment IS required.
Second, it really serves to prove the third party claim. If your doctor chicken’s out and does not even make the connection between these new treatments and the accident, then she is undermining the value of the patient’s third party clam.
Third, if the PIP adjuster again denies payment, that then will overcome any objection of the health insurer that they should not have to pay if there is auto insurance available.
In summary, the way your doctor chooses to respond will help or hurt your patient’s third party claim, and of course I am always going to want you to do all that you can to help injured victims.
OK, Betty, that about does it. I trust that my time here has produced some information that has been of value to you, and thus I would respectfully request that you take the time to locate the FEEDBACK FORM on this site and leave some feedback for me.
Best Wishes,
Dr. Settlement, J.D. (Juris Doctor)
http://www.SettlementCentral.Com
