Guest guest Posted March 13, 2012 Report Share Posted March 13, 2012 This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessaryâ€. There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? ph Medlin D.C. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2012 Report Share Posted March 13, 2012  Joe, The claims adjuster is trying to bully you ,don't let him get away with it. I would suggest fhat you get in touch with at Gatti & Gatti, I'll wager he'll succeed in getting you paid. Herb PIP Attorneys This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessaryâ€. There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? ph Medlin D.C. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2012 Report Share Posted March 13, 2012 Joe, consider sending the records to me for a file review and report if what you say is true then my report should support the clinical necessity of your curative treatment I can turn this around in a day or two since it’s a file review…then refer to patient to the Gatti law firm or whomever you tend to work with that knows PIP and they will threaten a PIP suit and the insurer will roll and pay your bills…Vern Saboe From: [mailto: ] On Behalf Of ph MedlinSent: Tuesday, March 13, 2012 5:13 PM Subject: PIP Attorneys This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessaryâ€. There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? ph Medlin D.C. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2012 Report Share Posted March 14, 2012 PIP could be flying by the seat of their pants with no documentation allowing the denial. More likely is a records review and report which they have not shown you. Submitting your own file review report may help, but once they get enough info to support a denial (i.e. their own report) my experience is the adjusters stonewall until you file the case. T. Hill, PC520 SW Sixth Avenue, Suite 1250Portland, OR 97204(503) 227-4330chill@...http://www.portlandinjurylaw.com From: [mailto: ] On Behalf Of vsaboeSent: Tuesday, March 13, 2012 6:23 PM'ph Medlin'; Subject: RE: PIP Attorneys Joe, consider sending the records to me for a file review and report if what you say is true then my report should support the clinical necessity of your curative treatment I can turn this around in a day or two since it’s a file review…then refer to patient to the Gatti law firm or whomever you tend to work with that knows PIP and they will threaten a PIP suit and the insurer will roll and pay your bills…Vern Saboe From: [mailto: ] On Behalf Of ph MedlinSent: Tuesday, March 13, 2012 5:13 PM Subject: PIP Attorneys This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessaryâ€. There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? ph Medlin D.C. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2012 Report Share Posted March 14, 2012 By law if the PIP does not send a denial in 60 days or less, they are accepting the payment as medically neccissary and HAVE to pay. If the denial for the care was not before 60 days they owe it, not sure when they sent you denials. Still get with an attorney but you also have rights as the laws are written. Hope that helps. Respectfully, Franchesca Vermillion, DCVermillion & Bloom, PCBalance & Fitness throughChiropractic Rehabilitation1750 Blankenship Rd Ste 295West Linn, OR 97068503-344-4378www.vermillionbloom.com From: spinetree@...Date: Tue, 13 Mar 2012 17:12:42 -0700Subject: PIP Attorneys This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessary”. There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? ph Medlin D.C. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2012 Report Share Posted March 14, 2012 This is not entirely correct. The insurance does not need to provide you a denial within 60 days, but they do need to provide you a notification either asking for more information or requesting a review or stating it is under investigation. Any of those will allow them to wait indefinitely to pay. The 60 day rule applies to each individual bill. So if you sent them the first bill 61 days ago, and they have not provided any notification pending payment, then they owe you for that days services. But if your next bills went out each week after, they are not obligated for any of them based upon the 60 day rule. That is why IME's can arbitrarily deny care 2 months prior to their examination and get away with it. Hill is correct, the PIP carriers will not change their opinion from additional information you or anyone else provided at this time. But you should provide it anyway, because when it does get filed for litigation, your rebuttal on a timely basis is valuable. dan miller On Mar 14, 2012, at 10:26 AM, Franchesca Vermillion wrote: > > By law if the PIP does not send a denial in 60 days or less, they are accepting the payment as medically neccissary and HAVE to pay. If the denial for the care was not before 60 days they owe it, not sure when they sent you denials. > > Still get with an attorney but you also have rights as the laws are written. > > Hope that helps. > > > > Respectfully, > > Franchesca Vermillion, DC > Vermillion & Bloom, PC > Balance & Fitness through > Chiropractic Rehabilitation > 1750 Blankenship Rd Ste 295 > West Linn, OR 97068 > 503-344-4378 > www.vermillionbloom.com > > > > > > > > > From: spinetree@... > Date: Tue, 13 Mar 2012 17:12:42 -0700 > Subject: PIP Attorneys > > > This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessary”. > > There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. > > I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? > > > ph Medlin D.C. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2012 Report Share Posted March 14, 2012 Well, in this case the patient came in with her claim number. We were sending all of our initial intake etc. to that ins. Company’s adjuster. As soon as they got our first billings, they contacted us to say that they were 3rd party. It then took another few weeks to track down the correct insurance company. Once found, we forwarded all notes and bills to them. The adjuster was very angry right off the bat.....denied the claim outright at first, then decided it was responsible for 3 visits..... we now phone the adjuster immediately in the case no matter what. ph Medlin D.C. From: Franchesca Vermillion Sent: Wednesday, March 14, 2012 10:26 AM 'Oregon DC's' Subject: RE: PIP Attorneys By law if the PIP does not send a denial in 60 days or less, they are accepting the payment as medically neccissary and HAVE to pay. If the denial for the care was not before 60 days they owe it, not sure when they sent you denials. Still get with an attorney but you also have rights as the laws are written. Hope that helps. Respectfully, Franchesca Vermillion, DCVermillion & Bloom, PCBalance & Fitness throughChiropractic Rehabilitation1750 Blankenship Rd Ste 295West Linn, OR 97068503-344-4378www.vermillionbloom.com From: spinetree@...Date: Tue, 13 Mar 2012 17:12:42 -0700Subject: PIP Attorneys This is a case I mentioned a while back where our patient (passenger and unrelated to driver) received treatment and the PIP insurance denied the bills outright sighting various flimsy reasons. I re-submitted for reconsideration. They finally responded again by paying for the patients bills for the first 3-4 visits and stating that the rest was “not medically necessary”. There was no IME done on this patient. Our records show a clear reasonable necessity of care throughout. She was treated from August 2011 – Dec2011. I have never seen anything like this and have not been provided with ANY reasoning for this decision. How can they deem it medically unnecessary if the patient was never IME’d? ph Medlin D.C. Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.