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PIP Claims & Medicare Recovery Claims


When a person is in an auto accident, normally their Florida personal injury protection (PIP) insurance will cover most medical bills. However, when someone is on Medicare or Medicaid, the procedure is somewhat different than it would be with a standard PIP claim. If you have been in a car crash and you have Medicare or Medicaid, it is important to make sure you follow proper procedure so that you or your estate is not hit with a bill to reimburse that you can ill afford.

Standard Procedure for PIP Claims

Florida is one of twelve states, as of this writing, to have no-fault auto insurance, meaning that regardless of fault, your medical bills will be covered, at least partly, by your own insurer in the event of an auto accident. Be advised that state law requires that any treatment must have started within 14 days of the accident, or no PIP coverage will apply. If you do seek medical treatment within that time frame, your PIP coverage will pay for 80 percent of all “reasonable expenses” for medically necessary care. Currently, acupuncture and massage are not considered ‘medically necessary,’ despite their benefits for many injured people, but most other specialists, including dentists and physical therapists, are usually covered.

Be warned that Florida law is extremely specific in that even with the 14-day requirement met, PIP benefits will be limited to $2,500 unless an emergency medical condition exists. The law defines an emergency medical condition as a medical condition manifesting itself with ‘acute symptoms of sufficient severity,’ where the absence of immediate medical care may reasonably be inferred to lead to serious jeopardy to a patient’s health, bodily functions, or organ health.

With Medicare or Medicaid

If someone is a Medicare or Medicaid recipient, the same procedure will usually be followed in auto accident cases (or generally in most personal injury situations). Medicare or Medicaid will pay some of your medical bills if your private insurer or workers’ compensation provider is refusing to do so. Then after a jury award or insurance settlement, it will request to be paid back. This is referred to sometimes as a Medicare ‘lien,’ but the correct term is ‘recovery claim’ (given that a lien requires that there be property involved as collateral, and it must be against the recipient of the medical care, when the majority of such recovery claims will be mounted against private insurance plans).

Be advised that while it is required to report accidents like this to Medicare and Medicaid (whichever one applies), it can take quite some time to receive a response or the relevant information about how much may be owed. The Centers for Medicare & Medicaid Services (CMS) is handling significant amounts of information, and very often cases simply wind up on the proverbial bottom of the pile. This does not necessarily mean that your settlement check must be delayed; rather, you can sometimes work with an insurance adjuster to place an amount estimated to be similar to Medicare’s demand request in trust, with the rest being made available to you.

Call An Experienced Attorney

Dealing with Medicare and Medicaid can be extremely complex on a good day, and undertaking it alone is asking for trouble in most cases. The Tampa PIP claim attorneys at the Rinaldo Law Group are well versed in these cases, and we are happy to share our experience and knowledge with you. Call our office today at 813-831-9999 to set up a free consultation.





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