Third District Court of Appeal Upholds Lower Court Decision That the Disparity in EMC Evaluations Does Not Violate Equal Protection
Last week the Third District Court of appeal upheld a lower court decision stating it was lawful to preclude a chiropractic physician from performing an EMC determination under the PIP statute, finding that part of the PIP statute did not violate the equal protection clause of the Florida Constitution. Progressive American Ins. Co. v. Eduardo J. Garrido, D.C., P.A.
Must a patient/insured obtain an EMC determination in order to have access to the full $10,000 in PIP benefits? Or is it the insurer’s duty to obtain findings that it is not an EMC?
This week the Fourth District Court of Appeal held that YES, the patient/insured must have an EMC determination in order to access the full $10,000 in PIP benefits; that if there is no EMC or if it is silent, the patient/insured is capped at $2,500 in PIP benefits. Medical Center of the Palm Beaches, d/b/a Central Palm Beach Physicians & Urgent Care, Inc., a/a/o Carmen Santiago v. USAA. To get the full picture and access the opinion, read on.
The final rule implementing Section 1557 of the Patient Protection and Affordable Care Act went into effect on Monday, July 18, 2016. Section 1557 is intended to promote equity in health care and prevent discrimination on the basis of race, color, national origin, sex, age or disability in health programs or activities that receive federal financial assistance. Compliance requires posting certain notices in your office and there are consequences for failure to do so if you are not exempt.
Entities that are subject to the Final Rule include physician practices. Read on for a brief outline of the requirements and guidance on who is exempt from this rule.
HMOs that offer services through a managed care system must offer that care through a system in which a primary physician licensed as a chiropractor is designated for each HMO subscriber upon request of a subscriber requesting chiropractic services.1 The designated chiropractic physician is responsible for coordinating chiropractic care the subscriber requests.2 Stated differently, a chiropractic physician must be assigned to each HMO subscriber who wants chiropractic care. That designated chiropractic physician is the gate keeper for that subscriber’s chiropractic care and either treats the subscriber or refers the subscriber to another chiropractic physician on panel for medically necessary care.3
In a lengthy and well written opinion, the Fourth District Court of appeal explained why Allstate’s “subject to” fee schedule language in its policy of insurance was insufficient to put providers and insureds on notice of how it would pay 200% of the Medicare Fee Schedule part B. In following prior appellate court rulings, the Court reiterated the law that there are two payment methodologies in PIP – the fact finding methodology of determining a “reasonable” amount and the fee schedule amount. The Court found that Allstate’s policy language did not contain the required “clear and unambiguous” language as to how it would reimburse PIP benefits.