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HICFs & PIP Coverage In Florida

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In Florida, when one is in a car accident, most people file claims with their personal injury protection insurer in order to have their medical bills paid. When adjusting PIP claims, insurers have used the Medicare fee schedule as a benchmark of sorts to arrive at a reasonable amount to charge for each visit or procedure. However, changes within the last five years or so have mandated that health care providers complete what is known as a Health Insurance Claim Form (HICF or HICA) along with the other required paperwork. HICFs can seem extremely confusing, however, when paired with the additional documents that an insurer can ask for. Understanding them can be critical to making sure your claim is paid.

PIP Claims Are Complex

 Florida law requires that anyone with a Florida driver’s license or a car licensed in Florida carry personal injury protection (PIP) insurance. The minimum required amount is $10,000 in PIP coverage and the same in property damage liability insurance (PDL). When someone is in a car accident, instead of bringing a lawsuit (in all but the most severe cases), they make a claim with either their PIP insurer or the insurer of the person who caused their injuries, depending on the situation. In order to have their bills paid, the victim advises their medical care team of the circumstances of their injuries, which then will be referenced when the provider makes a claim for reimbursement with either Medicare or the private insurer.

Florida state law requires that PIP coverage reimburse up to 80 percent of most charges. However, insurers have the right to adjust payments based on the fee schedules used by Medicare Parts A and B, which can change the amounts that will be paid by your insurer, especially if your private PIP insurance is not the only policy you may have to fall back on. Filing a correct HICF can go a long way toward ensuring that all your necessary treatment is well documented (which obviously increases the likelihood of your bills being paid without quibbling).

Check The Right Box

One very common misunderstanding that many people have when making a PIP claim is thinking that a HICF only has to be submitted if their claim is related to an automobile accident. In reality, the HICF has many different parts that can apply to all sorts of accidents – only one of them asks whether the claimant has been involved in a car crash. However, if that box is not checked, your claim will be denied as a matter of course, because the adjuster will lack all the information they might need to actually make a decision. This can become a problem if you are in an accident and a medical provider forgets to check the relevant box – you will then have to follow up and possibly wind up resubmitting all the paperwork, which can delay payments you may need in order to stay on your feet.

If the HICF is being sent to the Centers for Medicare & Medicaid Services (CMS), there may be additional issues. If you are a Medicare beneficiary, it is important to keep in mind that while Medicare will pay some of your bills, it will likely do so on a conditional basis – the general rule is that Medicare will not pay for items or services that either will be (or can reasonably be expected to be) covered by a private insurer. Thus, if you have a private insurer who is dragging its feet on paying your bills due to an error on your HICF, Medicare may pay everything – but then they will seek repayment from your insurer, or worse, from you, causing headaches when recovery should be your first priority.

Seek Help From Experienced Attorneys

Being in an accident is frightening at any time, and your primary focus should be on getting your life back to normal. However, insurers can make the process of reimbursement very confusing for the average person. If you have questions about your HICF or any other part of your PIP claim, consulting an experienced attorney is a good idea. The Tampa PIP insurance lawyers at the Rinaldo Law Group have been handling these cases for many years, and we will do our best to work for an outcome that is fair and appropriate for you and your loved ones. Call us today at 813-831-9999 to schedule an appointment.

Resources:

cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Beneficiary-Services/Medicares-Recovery-Process/Medicares-Recovery-Process.html

flhsmv.gov/ddl/frfaqgen.html#1

https://www.tampainjuryaccidentlaw.com/insurance-uninsured-motorist-claims/

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