In an ideal world there would be no need for your PIP (Payment Insurance Protection) claim to be arbitrated by anyone – the healthcare professional would simply present the bill and the insurer would pay it.
But we don’t live in an ideal world, which is why arbitration in these situations is often necessary.
And never more so than in the case of what is deemed to be a medical necessity by a doctor but not deemed necessary at all by an insurer.
Some Definitions
Personal Insurance Protection is an add-onto your car insurance that provides cover for medical expenses and/or a loss of income in the case of a motor vehicle accident.
Medical Necessities are treatments and protocols seen as necessary to your full recovery in the event of you being a victim of a car accident as agreed upon based on your Assignment of Benefits.
An Assignment of Benefits is where a patient signs a document stating that their insurer should pay the doctor or healthcare professional directly as part of their PIP coverage.
A PIP arbitration is basically a claim made by the medical professional to have their unpaid bills, for services rendered, paid to them by the insurer.
What happens in cases of PIP arbitration is that the insurer questions or refuses payment for certain types of medical expenses because they are not seen as a medical necessity.
This leaves healthcare professionals in the unenviable situation of swearing to uphold an oath that states, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing“, but then being unable to receive payment for healing the sick.
Why Insurers Decline Payments
The most typically cited reason is that the physician decided on a course of treatment for a patient that was not pre-certified by the insurer.
There’s a 50% penalty on payments where a treatment was now pre-certified by the insurer, even if that treatment was quite obviously a medical necessity.
In other cases, however, there arises a difference of opinion between the healthcare provider and the insurer as to what can be deemed to be necessary medical care.
What’s most important here is that a doctor is able to present clear documented evidence as to why they pursued a specific type of treatment for a patient.
It’s also worth noting that an insurer is required by law to respond to a request for pre-certification of a treatment within 3 days of it being issued.
This documentation is often the deciding factor in whether or not a medical professional can win their arbitration case.
Examples of Medical Necessity
Let’s use an example where a patient involved in a motor vehicle accident was advised that surgery was the best way to treat their injuries.
But on religious grounds, the patient refuses surgery and insists on using intravenous treatments instead, which will take several months to administer.
In this situation an insurer could put forward the case that surgery was a medical necessity whereas several months of intravenous treatment was not.
But as long as the medical records support this therapy, based on sound medical reasoning, then it can be deemed a medical necessity, but only through arbitration.
Summary
As you can see the area of PIP arbitration for medical necessity claims is quite complex. That’s why it’s always advisable to get legal counsel from an attorney experienced in this area.
Remember, a successful arbitration will result in you receiving payment in full for treatments you can prove were a medical necessity, regardless of the insurer’s opinion on the matter.