CAR CRASH NETWORK

Recent Court Decisions Affecting Medical Providers Ability To Recover Payments

car crash victim wonders who pays medical bills

If you are a medical provider who treats patients who suffered automobile accident-related injuries, two recent Supreme Judicial Court ("SJC") decisions, Boone v. Commerce Ins. Co. 451 Mass. 192 (2008) ("Boone") and Metro. Prop. & Cas. Ins. Co. v. Blue Cross & Blue Shield of Mass., Inc. 451 Mass. 389 (2008) ("Metropolitan") will impact your right to recover payment of those auto accident related patients' bills from the applicable automobile insurance companies ("auto insurer").

First, Boone addresses who an auto insurer can direct to perform an independent medical examination ("IME") of your patients. An IME is an "in-person" examination by a medical professional hired by the insurer to determine the reasonableness and necessity of treatment to its insured. Even though you are not a party to the contract upon execution, Massachusetts law uniquely allows you to recover directly from the auto insurer payment of your patients' "reasonable" bills for "necessary" treatment.

The Boone decision overturned the Appeals Court decision, which held that an auto insurer could not use an IME opinion to refuse payment of its insured's accident-related bills unless the IME was performed by a medical professional of the same licensure (i.e., a chiropractic patient needs to be examined by a chiropractic IME doctor.) This was called the "same profession" requirement - the same requirement that is mandated by statute regarding record reviews as stated in M.G.L.c.90 Sec.34M (PIP Statute). Now, the SJC made clear that the insurance company was not in violation of law by refusing payment of bills based on IMEs performed by medical professionals not of the "same profession". Even though auto insurers must have record reviews performed by a provider of the same profession, the auto insurer can

Now, the SJC made clear that the insurance company was not in violation of law by refusing payment of bills based on IMEs performed by medical professionals not of the "same profession". Even though auto insurers must have record reviews performed by a provider of the same profession, the auto insurer can refuse payments of your medical bills based upon the IME of a provider not of the "same profession" but qualified to treat patients with the same type of injuries. The Court reasoned:

"There is some overlap among practitioners who are licensed in different practice areas. For example, orthopedics is defined as a medical specialty concerned with the preservation, restoration, and development of form and function of the musculoskeletal system, extremities, and the spine; "chiropractic" is defined as the relationship between the musculoskeletal structures and functions of the body, particularly of the spinal column and the nervous system. Therefore, a licensed orthopedic surgeon would be qualified to treat most of the same type of injuries that a chiropractor could treat."

The Boone decision not only lays out a framework by which the auto insurer can refuse payment based on an IME but also lays out a framework by which a medical provider can challenge the IME. For example, you can still challenge the opinion of the IME and/or challenge the competency of such IME provider. Accordingly, when an insurer relies on an IME to refuse your payments, you may still challenge such decision for reasons including, but not limited to, (1) whether the examiner was qualified to render opinions relative to the reasonableness of your treatment; (2) whether the examiner was qualified to treat and give opinions on the type of injuries the patient sustained; and (3) whether the examiner properly examined the patient by administering the proper tests.

Second, the SJC also recently decided the Metropolitan case, which affects the medical provider's right to access the Medical Payments (hereafter "MedPay") portion (Part 6) of the Standard Massachusetts Automobile Policy. The SJC decided that a health insurer may defer payments for treatment of an autoaccident victim until MedPay exhausts its available benefits. (The Blue Cross Blue Shield policy at issue had deferral language stating that health insurance coverage was secondary coverage). Even though MedPay is not compulsory insurance, the SJC reasoned that a health insurer may require all primary insurers (including the MedPay insurer) to pay benefits before the health insurer will pay the bills.

The practical effect of this decision is as follows: 1) Once the PIP benefits have been exhausted by the insurer, the medical provider must "coordinate benefits" by submitting the patient's bills to the patient's health insurance; 2) the health insurer can then defer coverage to the MedPay portion (if the patient has MedPay) of the insured's auto insurance for further payment; 3) the MedPay insurer must pay reasonable and necessary accident-related bills up to the limits of its coverage before the health insurance pays.

Accordingly, medical providers should submit bills to its patients' health insurers after PIP coverage has exhausted $2,000.00. If, however, the health insurer defers further payments to primary coverage, the medical provider should seek recovery from all applicable MedPay policies before health insurance will pay.

Mark Cirigliano is an attorney with Cirigliano and Associates who represents medical providers in insurance coverage and collections matters. Attorney Cirigliano can be reached by phone at 617-442-2018.