The Initial PIP Patient Encounter: An Opportunity to Obtain the Proper Documentation to Avoid Bill Denials and Payment Delays  

The first priority for all health care providers is treating his or her patient.  However, when it comes to proper payment for that treatment, documentation to establish eligibility for PIP reimbursement is critical.  The first patient encounter results in an enormous amount of paperwork for both the PIP patient and the health care provider.  With so much documentation exchanging hands it is easy to miss documents that will be needed when time for payment comes around.  Here are a few ideas for documentation that will help make obtaining PIP payments for treatment run smoother.

 

Assignment of Benefits

First and foremost, the key document for PIP reimbursement is the Assignment of Benefits (“AOB”).  This document allows health care providers to obtain payment directly from insurance companies.  While all providers have some form of AOB, many contain language that is routinely challenged by insurance companies.  The language of an AOB should give the health care provider the right to obtain payment directly from the insurance company and to proceed through any other means available, such as through arbitration or the courts, in order to obtain payment.  This allows the health care provider to proceed to arbitration or lawsuit if the insurance company denies payment for any reason.  The AOB should have the health care provider’s name prominently displayed to show that it pertains to that specific health care provider.  It should also be clearly signed and dated by the patient or guardian with a printed name to avoid any ambiguities that the insurance company may see as a reason to deny payment.

 

PIP Application

Apart from the AOB, the PIP application is the most important document needed when seeking PIP benefits from an insurance company.  This document conveys much of the information the insurance company needs to establish eligibility for coverage including policy number, insured’s name, patient’s address, accident location, injuries, and lost wages.  Failure to provide this foundational document results in the denial of many claims.  This document acts as a first step in opening up a claim for a health care provider for PIP benefits.

 

HIPAA Release

Under the Health Insurance Portability and Accountability Act (“HIPAA”), patient privacy was made a byword for all health professions.  All health care providers take this requirement very seriously.  While maintaining the highest standards of privacy, at times the sharing of medical information is necessary for consistent continued treatment between health care providers and for legal professionals who seek PIP reimbursement for treatment performed.  A standard HIPAA release for medical information is a legal document that allows providers or legal professionals to obtain medical documentation to facilitate continued treatment and to provide records to show the “medical necessity” of treatment in order to obtain payment.

Many times a PIP patient is referred to one health care provider from another for the purpose of continuation of treatment.  This health care provider may need medical documentation that he or she does not already have.  In addition, when a legal professional is attempting to establish “medical necessity” for the treatment of one health care provider, it is necessary to have the medical records of another provider.  As a result, a HIPAA release is a valuable tool to obtain this documentation when needed.  It is recommended that during the initial patient visit, a HIPAA is signed and dated by the new patient, allowing you “and your legal representatives” to obtain medical records from other treating physicians or MRI facilities.

It is very important to explain to the patient what the release means when it is presented to them for signing and the limited uses for which the release can be utilized.

 

Affidavit of No Insurance

In many instances in PIP, the patient will be seeking benefits from someone else’s automobile insurance policy.  This occurs when a patient has no insurance of his or her own and is seeking PIP coverage through a resident relative or the owner of the vehicle in which he or she was an occupant.  When this occurs, the insurance company that is billed for treatment rendered is very curious as to what other coverage the patient may be entitled to.  To obtain this information, the insurance company will require an uninsured patient to sign an Affidavit of No Insurance (“AONI”).  The AONI is a sworn document contemporaneously signed by a Notary Public which identifies a patient’s address; whether he or she was a named insured under a policy of automobile insurance; who he or she lived with; the relationship to the patient; and whether any of those people with whom he or she lived had their own automobile insurance.  This is done in order to see if there is other coverage within the household that would be liable for payment of PIP benefits.  Many insurance companies will deny benefits to a provider if this documentation for such payments is not provided.

While not exhaustive, these documents will facilitate prompt payment of claims and avoid many eligibility issues that may arise.

 

For more information please visit:

www.callagylaw.com

www.callagycounsel.com

 

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