In order to pursue a Personal
Injury Protection (PIP) claim on behalf of a medical provider, several documents
are critical. There are also several
documents that are important but not necessarily essential. Discussed in detail below are both the documents
that are critical to pursuing a PIP
claim successfully and those helpful but not necessarily indispensable.
First and foremost among the documents critical to a PIP
file is the Assignment
of Benefits, or AOB. Prior to execution of an AOB by the patient,
there is no relationship between the PIP carrier
and the medical provider when it comes to that patient’s medical treatment. The relationship exists between the carrier
and the patient through the auto
insurance policy, not between the medical provider and the carrier. Through the AOB, the patient transfers to the
medical provider his or her right to be reimbursed by the carrier for the
medical treatment. Without the AOB, the
claim cannot be arbitrated.
Also critical for a PIP claim is the Explanation
of Benefits (EOB), which serves as the evidence of what the carrier paid
and its justifications for paying or not paying in the manner it did. Without the EOB, it is
impossible to challenge the carrier’s position, because there would be no clear
understanding of the carrier’s position.
Finally, the bill—HCFA or UB—along
with the medical records supporting the bill are critical. The bill, of course, sets forth the expected
payment, and the medical records supporting the bill are the proof that the
services were rendered. Depending upon
the reason for the denial or underpayment, the medical records supporting the
bill might not be enough to succeed on the claim, but, at a minimum, clinical
records are needed to prove the services were actually rendered.
Examples of additional clinical
records that might be needed are the treating physician’s treatment records
preceding the date of service being arbitrated.
If a facility, such as a hospital or ambulatory
surgery center, is seeking reimbursement for a procedure performed by one
of its surgeons, and the carrier denied reimbursement on the grounds of medical
necessity, the operation report describing the procedure is a critical part of
the claim, but it does not help to establish the medical necessity of the
procedure. It describes the procedure
but does not justify it. Similarly, if
the provider is a pharmacy or durable medical equipment (DME)
provider, the prescription for the drugs or equipment is necessary, but does
not prove the drugs or equipment were medically necessary. The treating physician’s notes are needed for
that.
Often the best approach is to include in the file all the
available medical records from beginning of treatment to the end, including pre-certification
requests, with fax confirmations, and insurance correspondence in response to
the requests. This would include medical
records from other providers, assuming they are available. For example, having an Emergency Room record
might help prove medical necessity of physical therapy treatment 6 months after
the date of injury. Also helpful, though not critical, are the
police report, the insurance declaration page showing the policy limits, and
the PIP
application.
The expression “Less is More” does not really apply to PIP
arbitration, at least not at the stage when the relevant documents are being
assembled. It is always helpful to
include more documentation, especially clinical records, in the material
initially assembled to pursue a claim, rather than less. In this case, “More is More, Not Less.”
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