2. Upon referral by a provider described in subparagraph 1., followup services and care consistent with the underlying medical diagnosis rendered pursuant to subparagraph 1. which may be provided, supervised, ordered, or prescribed only by a physician licensed under chapter 458 or chapter 459, a chiropractic physician licensed under chapter 460, a dentist licensed under chapter 466, or, to the extent permitted by applicable law and under the supervision of such physician, osteopathic physician, chiropractic physician, or dentist, by a physician assistant licensed under chapter 458 or chapter 459 or an advanced registered nurse practitioner licensed under chapter 464.
This is a very important part of the new PIP law which I think has been overlooked by many people. I think insurance companies are going to try to reduce/deny payment for treatment based on this small phrase "consistent with the underlying medical diagnosis".
For example, consider this scenario:
Patient goes to a hospital because they hit their head on the steering wheel, lost consciousness for a minute, and bled from their forehead. Let's assume the hospital used ICD9 diagnosis code 850.9 (Concussion, unspecified). After leaving the hospital the patient shows up at a local chiropractor's office for neck pain. Patient never had neck pain before the accident and only felt the pain a couple of days after the accident. The chiropractor submits a HICF with ICD9 diagnosis code 847.0 (Cervical Sprain/Strain)
Insurance company argument:
Some insurance companies are going to argue that "consistent with the underlying medical diagnosis" means the ICD9 code. In this case, the initial diagnosis code was for a concussion (850.9) and the treatment for the neck pain (847.0).
I would argue that the neck pain was obviously directly related to the accident because the patient never had neck pain prior to the accident and only experienced the pain a few days after the accident. The portion of the law talking about "consistent with the underlying medical diagnosis" does not mention an ICD code. The PIP statute does mention ICD diagnosis codes in other parts of the statute so Florida Legislators knew what an ICD9 code is and could have added that in this section.
Also, when the patient was getting treated at the hospital, the emergency room doctor was more concerned about her concussion than about her "soft tissue" injury which, as we know, the MD would only refer some pain meds for.
If the insurance company denies your bills claiming that they are "inconsistent with the underlying medical diagnosis" then you need to contact a PIP attorney to discuss your case.
Abraham Ovadia, Esq.
Florida PIP Law Firm, PA
I'm a PIP attorney who specifically helps medical providers when PIP insurance doesn't pay. I tell my clients that if PIP isn't going to pay above $2,500 then forward the claim to my office so I can review whether the insurance company is correct. My services are on a contingency basis and all consultations are free and at no obligation!
Our office works at no out-of-pocket expense to the medical provider. All money is collected directly from the insurance company.
No recovery, no fees or costs!
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:
-serious jeopardy to patient health, and/or
-serious impairment to bodily functions, and/or
-serious dysfunction of any bodily organ or part."