When someone is hurt in an accident in Florida, they may need to file a claim for compensation to cover the cost of medical treatment. But sometimes, the insurance provider can issue a 627.736(6)b request to the medical provider asking for additional information to verify the claim’s authenticity.
The problem is that medical providers are often confused when they receive a statutory 627.736(6)b request in Florida. That’s why these requests are frequently ignored. If the request goes unreciprocated, the medical provider’s bills are legally not overdue.
If you’ve been required to furnish a written report to the insurer, contact a personal injury attorney lawyer to help you do so and speed up the claims process. You can find more information below if you have questions regarding a 627.736(6)b request.
What Is a 627.736(6)b Request in Florida?
Under the no-fault law, an insurance provider must pay bills within 30 days of receiving receipt to avoid a penalty, interest, or lawyer fees. But this time isn’t enough for the insurance provider to investigate a potentially fraudulent claim.
Florida personal injury protection statute, Section 627.736(6)(b), allows insurers to ask for more information or documentation from the medical provider. Doing this helps delay the time when a payment is due, allowing the insurer to thoroughly assess the claim look into it, and decide whether to pay the bills.
According to Florida Statutes Section 627.736(6)(b):
“Every physician, hospital, clinic, or other medical institution providing, before or after bodily injury upon which a claim for personal injury protection insurance benefits is based, any productions, services, or accommodations concerning that or any other injury, or concerning a condition claimed to be connected with that or any other injury, shall, if requested by the insurer against whom the claim has been made, furnish a written report of the history, condition, treatment, dates, and costs of such treatment of the injured person and why the items identified by the insurer were reasonable in amount and medically necessary.”
The primary purpose of this legislative tool was to allow the insurer to look into any unsubstantiated claims before issuing payments. However, insurance providers are using this tool to stall and dismiss claims.
In a conventional Florida PIP claim, the healthcare provider must send the insurer their bill within 35 days after the treatment date. The insurance provider then has 30 days to conduct an inquiry and settle the claim.
If 30 days pass without payment, the bill is considered overdue, and the medical provider can send an overdue bill demand letter to the insurer.
However, the 30 days payment period is virtually “paused” if the insurance provider submits a written 627.736(6)(b) request in response to the filed bill before the provider produces the required documents.
The PIP Statute mandates that when a provider delivers the needed paperwork, the insurer must pay the provider’s bill within ten days of receiving it.
Can Your Problem Go Away If You Ignore A (6)(b) Request?
There would be a huge problem if a medical professional ignored the statutory 627.736(6)b request in Florida and began the demand process. First, the insurance provider’s duty to make payment within 30 days of receiving notification of the bill is suspended until their request is met.
Besides, the bill won’t be overdue if the request is never fulfilled, so it would be premature to send a demand letter or file a civil lawsuit. Medical providers should be familiar with a (6)(b) request to ensure their invoices are paid on time.
You may see these requests in the “explanation” section of the provider’s Explanation of Benefits. In other circumstances, the request may be sent after the provider has written the insurer a demand letter.
Providers should treat all (6)(b) requests seriously, whether sent as a demand letter or an explanation of benefits. Although it may be inconvenient, providers are compelled by law to respond to requests for further information to recover their benefits.
You shouldn’t be worried about the fees of mailing in paperwork. According to Florida’s PIP Act provision, the person requesting such records must cover all necessary expenses.
Therefore, if you submit information to the insurer in response to a (6)(b) request, you shall also include an invoice for any fees incurred.
Current State of (6)(b) Caselaw in Florida
In a ruling released on August 31, 2016, the Fourth District Court of Appeals created a precedent that would guide the State of Florida’s interpretations of Emergency Medical Conditions (EMCs) and (6)(b) petitions.
The first DCA court to comment on the matter of EMC is in the case of MEDICAL CENTER OF the PALM BEACHES d/b/a Central Palm Beach Physicians & Urgent Care, Inc. a/a/o Carmen Santiago, Appellant, v. USAA CASUALTY INSURANCE COMPANY (4th DCA, 2016). That indicates that in the foreseeable future, Florida must abide by the ruling in this case.
According to the case, the question is whether Florida’s PIP statute requires a competent medical professional to determine that a patient has an EMC to get compensation exceeding $2,500.
In other words, would the PIP-covered benefits be capped at $2,500 if a determination revealed that the insured doesn’t have an EMC or if the determination wasn’t conducted?
The case further shows that the statute calls for a determination of an EMC before insurance can pay up to $10,000 in benefits. Lastly, the benefits would be capped at $2,500 if there has been no assessment of whether the insured has an EMC or a determination that they don’t have an EMC.
Understanding the Context of Florida’s (6)(b) Statute
Carmen Santiago, an insured party, suffered injuries in a car accident. She visited an urgent care facility because of her neck and shoulder pain.
The medical professional referred her for physical therapy. The physical therapist (appellant in this case) then presented invoices to appellee USAA, the insurer, for payment.
However, USAA refused to make a second payment, stating they had compensated $2,500 covered under the policy per section 627.736(1)(a)(4) of the Florida Statutes.
For USAA to make additional payment, USAA demanded that the appellant produce a determination of the patient’s emergency medical condition (EMC) approved by a physician.
The appellant filed a lawsuit against USAA for violating the insurance contract and refusing to offer full reimbursement for the medical care provided.
The treating doctor for the insured, Dr. Chang, then sent a letter to the appellant stating that he believed the insured to have an EMC. Upon receiving these supporting documents, USAA paid all pending costs up to the policy limits.
The requirements of section 627.736(1)(a)(3)-(4) limit medical benefits to $2,500 unless it is determined that the insured had an EMC, according to USAA’s motion for summary judgment, which the trial court approved.
The trial court also found that USAA had the right to ask the appellant for details about the insured’s medical condition per section 627.736(6)(b) to justify further compensation.
The appellant claimed that USAA ceded all defenses since it made the medical payment after the appellant filed a lawsuit. However, the trial court disagreed and found no confession of judgment. That means USAA did not improperly withhold payment.
The Need to Respond to EOR/EOB Requests
The crucial question, in this case, is whether a request for determination of an emergency medical condition would be handled the same as a 627.736(6)(b) request in Florida.
According to Florida Statute 627.736(6)(b):
- Upon request by the insurer, a physician, hospital, or other medical institution must issue a written report of the history, medical condition, treatment, dates, and costs of provided treatment.
- Provide a sworn statement that the services or treatment provided was reasonable and critical based on the bodily injury sustained.
- Allow the review and replication of their medical records concerning such history, condition, treatment, cost, and dates of treatment as long as it doesn’t affect the introduction of evidence at trial.
What Florida medical providers should include in a sworn statement
A sworn statement should read: “Under penalty of perjury, I declare that I have read the preceding and that, to the best of my understanding and belief, the facts described are accurate.”
Any doctor, clinic, or other medical institution that complies with this clause cannot be sued for breach of the physician-patient privilege or invasion of privacy.
All reasonable costs associated with obtaining such records and such a sworn declaration shall be covered by the party requesting them.
If an insurer requests information or documents under this paragraph within 30 days of receiving notice of the amount of damages under clause (4)(a), the amount or partial amount subject to the insurance provider’s inquiry is overdue if they don’t pay as required in clause (4)(b) or within ten days of receiving receipt of the requested documents, whichever comes later.
The word “receipt,” as used in this clause, includes but is not limited to examination and copying done according to this clause.
Under the insurance law, an insurer who demands evidence or information on the reasonableness of costs or medical necessity under this clause without a legitimate reason for doing so is indulging in unfair trade practices.
Florida district court’s interpretation of the (6)(b) statute
The phrasing of the criterion to qualify that asking for an EMC determination was essentially asking for the patient’s condition as specified in 6b attracted the court’s attention in this case.
As State Farm v. Delray Medical Center, 178 So. 3d 511, 515 (Fla. 4th DCA 2015) confirms, the simple language used in this subsection and its title shows that the objective of this provision is to find documents relating to the treatment and associated billing of the injured person.
USAA requested a report on the insured’s medical condition in the cited case. The report may have influenced USAA’s assessment of whether the insured’s injuries qualified as an EMC after being diagnosed by a licensed healthcare professional.
The demand letter from the appellant was, therefore, premature. Despite having submitted a letter demanding payment of benefits, the appellant did not reply to USAA’s request for discovery as required by § 627.736(6)(b).
How Does This Impact Florida Medical Providers?
Medical professionals may face problems as a result of the determination mentioned earlier. This case shows that you will be subject to a (6)(b) request if you get an Explanation of Benefits or Explanation of Review that they need information on the patient’s condition or EMC status.
You must provide the EMC determination or the patient’s condition in response to this inquiry. There will be two consequences if you don’t respond.
- Your bill won’t be considered “overdue.”
- Your lawyer can’t send a demand letter on your behalf.
Remember that Demand Statute 627.736(10) only allows you to demand “overdue” claims. If you ignore the request and don’t send the dates of service to your attorney for demand, your attorney can’t claim those dates till you turn in the EMC determination.
That means you must wait ten days after receipt and another five days for mailing before informing your lawyer of the dates to demand payment.
What to Do When You Have Sent the Insurance Company Everything You Have on the Patient
Only some requests labeled as a (6)(b) request will be considered one by the courts, as stated above. They can’t just request random things and get them.
The request must be consistent with the statute’s text or intent. The courts have concluded that some demands are not covered by clause (6)(b).
So, what do you do after sending what you have? It is advisable not to disregard the letter. Instead, compose a letter to the insurance provider.
In your letter, state that your office has provided all the documentation that you have. Ask the insurer to consider this letter as your response to the alleged request and inform them that you will leave the bills overdue and send a demand letter under Florida Statute 627.736(10) if they fail to respond within ten days.
But how does this letter benefit your office? Your letter doesn’t have to acknowledge the legitimacy of their request. It serves as a rebound, sending the ball back to their end and giving them ten days to decide.
But after ten days of receiving the letter (you can allow them 15 days), your bill is overdue. You may now send the file to the PIP claims lawyer, who will handle it from this point.
Contact an Attorney to Help with Your Florida PIP Claim!
If you are a medical provider and your PIP benefits were denied, or you received a 627.736(6)b request in Florida, contact a lawyer for help.
At Legal Giant, we partner with skilled personal injury lawyers who are familiar with the complex process of navigating insurance claims.
Our partner attorneys can help you file the appropriate documents with the insurer and ensure that the claims process runs smoothly.
Contact us for a free case evaluation today.
