Personal Injury Information by Find-A-Code

by  Find-A-Code
May 7th, 2015

Personal Injury is an complicated subject as it relates to medical services. This page contains helpful information as an additional resource to Find-A-Code's specialty-specific Reimbursement Guides.

Note: State laws regarding personal injury claims vary from state to state. Therefore it is crucial for healthcare providers to understand their own state requirements.

Sources of Medical Expense Recovery for Personal Injury Care

Here is a non-exhaustive list of commonly used sources for medical expense recovery. Each state has a specific standard, which may or may not use any of these described sources. You should consult with your state association for a list of applicable sources. If any of these or similar types of medical benefits coverages are not available, then you might consider reimbursement by cash or medical expense financing.

If Personal Injury benefits are exhausted or not available, this should be noted in the patient record along with supporting documentation. In this situation, if standard health insurance or another type of coverage is available, then the patient may elect to have reimbursement requests for continued care submitted to their health insurance carrier. DO NOT bill both the PI carrier and health insurance carrier simultaneously.

In the event of a personal injury accident, the personal injury insurance carrier will be responsible until the provider is notified otherwise. All verbal communication should be thoroughly documented. Due to limitations and rules of coverage with PI insurances, providers should make communication with the PI carrier a priority as the patient progresses through care.

“No-Fault” States

A minority of states have enacted No-Fault automobile insurance laws within their jurisdictions. No-Fault laws usually entail the following requirements or principles:

Coding and Billing

For Personal Injury, use the standard code sets for procedures (CPT) and diagnoses (ICD). It is also important to use the “E” codes in the Diagnoses section of this book to specify the external cause of the injury (e.g., auto accident codes V40-V49). Carriers usually accept claims submitted on a 1500 Claim Form. Verify specific coding and billing requirements with the personal injury insurance.

Attorneys have specific requirements for the type, timing and quality of reports which are required for administrating a successful claim for their clients. Reports are not patient clinical records. Check with the representative of record for their reporting requirements. Attorneys may request office notes and charges accompanied by a narrative report. Before preparing a long narrative, confirm that this is what is being requested. Often, attorneys will be satisfied with a brief summary describing the status of the patient at the conclusion of care. It is important to maintain HIPAA’s Privacy standards by obtaining the proper authorization from your patient prior to releasing records or reports.

NOTE: A HIPAA authorization for release of PHI is included with the Complete & Easy HIPAA Compliance publication available in the online store (Resource 116).

Claims adjusters enter the information from the claim form and the patient charts into their computers. Their software program (such as Colossus, Mitchell Medical, etc.) then evaluates your claim. A check is then authorized for their approved procedures. It is important to review their payment reports to identify any portion of your services that are denied or bundled. In some cases a corrected statement could resolve a problem. In other cases an appeal could be necessary to require them to follow accepted national guidelines (e.g. CPT, NCCI edits, etc.). Ultimately, when an account is not paid in full, the final resolution may require a legal solution against the insurance carrier.

Personal Liability Compensation

Financial liability for Personal Injury incidents goes beyond physician services which help restore patients to their pre-accident condition. When assessing liability, many factors related to the collision/accident need to be considered. This includes conditions such as abrasions, cuts, contusions, fractures, etc. as well as work time loss, pain and suffering. All these conditions, known as “value drivers,” are considered when the computer software determines a settlement offer. The dollar range for the “settlement offer” is then conveyed to the claims adjuster. Therefore, it is critically important that every aspect of these types of visible and non-visible injuries be documented in the initial physician’s report, even though another provider may be treating the other injuries. For example, common auto injuries, such as lacerations, may not be treated by a chiropractic physician, but they may delay treatment as the doctor waits for them to heal before being able to perform spinal manipulations in the affected areas.

Fee Schedules for Personal Injury

Each payer will have their own fee schedules; however, some state legislatures have mandated Personal Injury Protection or MedPay fee schedules. It is interesting and valuable to note that state laws can vary.

Key Legal Issues to Resolve

The fact that personal injury commonly involves several different sources of payment means that, in certain instances, chiropractic physicians have a greater chance of being paid in full. Nevertheless, several key legal issues need to be answered in each state before time and energy is invested in discovering, verifying, and billing the various sources of payment. These issues include:

The answers to these questions depend largely on (1) which state law controls in any given personal injury case, and (2) how the controlling law addresses each issue. At a minimum, chiropractic physicians are encouraged to understand the relevant laws in their own states.

Discovery of Insurance Information

There are numerous ways of obtaining automobile insurance information in any given PIP case. The following represent some of the key ways:

In the case of business insurance, chiropractic physicians should simply call the place of business and inquire as to who their insurance carrier is, and then call that insurance carrier to verify coverage.

Essential information needed before submitting claims to an adjuster usually includes the insured’s name, the policy number, the date of the accident/loss, the personal injury claim number assigned to the case, the name and address of the adjuster, and the preferred method of billing.

Generally, liability and UM adjusters request a list of charges upon “release from care.” PIP and MedPay carriers usually accept claims submitted either on a 1500 Claim Form, or on their forms.

Liens and Assignment

Letters of Protection (Resource 160), a.k.a. Personal Injury/Medical Liens, should be used by every chiropractic office that provides injury recovery care to car accident and other personal injury patients. These liens are a simple and effective way to help ensure that you get paid from the proceeds of the patient’s insurance settlement for injury recovery services that you provided to them. However, many providers don’t know how to draft or effectively use them. Depending on how you draft your assignment and lien and the protocols you follow, you can solve a host of payment problems in the area of health insurance and all forms of accident insurance. Knowledge can save tens of thousands of dollars in lost revenue, as well as stress, aggravation, and lost time.

When you have a patient sign a lien, it’s important to have that lien filed with the attorney on record. It’s equally important to document that the attorney has received your lien as well. Not all attorneys will sign a lien and send it back to you. If you do not confirm the receipt of your lien with your patient’s attorney, you can find yourself at the mercy of your patient, their client! Attorneys have their first responsibility to their clients. If the client chooses to instruct the attorney not to pay your bills, even if that attorney happens to be a close friend or family member to you, that attorney must follow the client’s instructions and not pay your bills!

If an attorney has accepted your lien, they have a legal obligation to pay your bills from the settlement proceeds, even if your patient instructs them otherwise! So get that lien signed by your patient and their attorney as soon as possible! There are many methods to prove receipt of lien by the attorney, but a returned signed copy is best. While liens appear to be a great legal instrument to force payment, they are not foolproof. Most liability insurance company's do not recognize the legal obligation of a Chiropractors patient lien. In many states when patients file for bankruptcy, they will subject your lien to steep discounting or even dissolution, with only a hospital and attorney lien being able to survive the bankruptcy. Do what you can to get Chiropractors included in that same hospital lien survivability category.

It is important to be aware of individual state laws regarding the assignment of benefit provisions. For example, in the state of Virginia, the law requires the provider to bill the health insurance first if they are an in-network provider.

CLICK HERE for more information on liens and a sample lien agreement.

Attorneys

Patients

Payers

PIP or Medpay Payers

Attorneys Have Obligations

There is a body of law that is triggered when you have a well-drafted assignment and lien in hand and follow a few simple protocols.

In the late 80’s, the American Bar Association (ABA) adopted a model rule of professional conduct for the legal profession, entitled “Safekeeping Property Merits Special Attention.” According to Rule 1.15(b), when an attorney receives funds in which a client or “third-person” (e.g., a health care provider) has an “interest,” three duties are triggered: 1) the attorney has a responsibility to promptly notify you of the receipts of the funds, 2) the attorney has a responsibility to promptly pay you based on your interest, 3) the attorney has a responsibility to provide you with a “full accounting” upon request. Knowledge of this rule has been helpful when it comes to collecting outstanding balances in any type of accident case. Whether and how this rule applies in each state can vary based upon the laws of the state.

The ABA Rule 1.15(b) represents just one body of law that supports a well-drafted assignment and lien. Those who spend just a little bit of time for the assurance of a well-drafted assignment and lien, and then follow-up with simple protocols discover how easy it can be to solve many types of payment issues.

Key Elements in Your Lien and Assignment

Many providers don’t know that there are different types of assignments and liens, and that assignments are different from liens. Additionally, each type serves a different purpose. A federal bankruptcy court once explained that the basic difference between an assignment and a lien is that an assignment transfers ownership over the proceeds, while a lien does not. The meaning of the court’s statement was that an assignment of the proceeds will have a better chance of surviving a bankruptcy proceeding, whereas a lien has less of a chance.

Avoid assignment and lien documents which are very limited, because they could fail to include all types of payers and/or all types of proceeds. Don’t restrict your document. Include at least two provisions in your assignment and lien document: 1) a direction to all payers to pay you promptly, directly, and exclusively in your name, 2) include some key definitions of words like “payers,” “proceeds” and “charges.”

Uniform Commercial Code Lien

All states have some form of a health care lien; however, an increasing number of providers have become aware of a universal type lien known as the “Uniform Commercial Code” or “UCC” lien. The lien is available in virtually all states. It’s easy to file and costs as little as $5.00 in some instances. In various jurisdictions, filers are able to submit the lien form electronically. Furthermore, the UCC lien doesn’t have the limitations which many other health care provider liens seem to entail (for example, the Virginia “medical lien” law is limited to $500 for chiropractors). Does the UCC lien law really protect health care providers? Here is an excerpt from the Texas UCC law, it is nearly identical in most states:

“The following security interests are perfected when they attach: ...5) a security interest created by the assignment of a health-care-insurance receivable to the provider of the health care goods or services.” -Texas Business and Commerce Code, Section 9.309

Conclusion

When you accept a PI patient, you are accepting a responsibility to be a healthcare provider for the acute traumatic care injury services that your patient may need for an optimal recovery. Because PI claims are handled differently than regular medical claims and PI laws vary from state to state, it is essential to understand these differences.

Close communication with patients, auto carriers and attorneys (as may be necessary under certain circumstances) is essential. This ensures that necessary claim information is collected and also helps avoid misunderstanding or oversights regarding claims submission and payment.

Monitoring Personal Injury claims on a frequent and regular basis with auto carriers and/or attorneys (where applicable) is a measure of efficiency and protection for both the patient and the provider. Also, collecting the proper letter of protection or lien is a protective measure which can help the practice avoid potential reimbursement complications. Documenting your practice’s personal injury claims procedure in your Policies and Procedures manual helps to ensure a smooth and seamless process.


Personal Injury Information by Find-A-Code. (2015, May 7). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/personal-injury-information-resource-329-25256.html

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