Answers to Common Insurance-Related Questions

By Richard H. Adler, Attorney at Law

We are frequently asked by health care providers to problem-solve situations involving their patients’ personal injury claims. The questions asked are often times similar, even though they come from many different types of providers throughout Washington. This is our attempt to address some of the more common questions we have been asked over the last several months.

Scenario #1

The doctor wrote a report at the request of the PIP insurance company. The narrative report was two pages in length and the doctor charged a $200.00 fee. The PIP insurer sent the doctor a check for $75.00 and refused to pay the $200.00 charge. The doctor was upset with the insurer’s approach and wanted to know what remedies were available to him.

Answer: A great way to avoid miscommunication about the reasonableness of a narrative report charge is to request prepayment from the insurer for the report. This can be addressed by the following:

Dear Insurer:

We have received your request for information regarding (patient’s name). The doctor’s fee for a dictated report is $_________. Upon receiving your check for this amount, the report will be mailed to you promptly.

The obvious advantage to a “prepayment policy” in your office is that you will be paid in advance for your time. If the insurance company wants a different type of report requiring less effort on the doctors part, you will know that when they respond, “We will only pay for a $75.00 report.”

Since prepayment was not requested in Scenario #1, one option for the doctor is to notify the patient’s attorney and request assistance in communicating with the PIP insurer.

Another option is to talk with the PIP adjuster’s supervisor and explain the circumstances; it was their request for a report, they did not specify whether they wanted a short or long report, and a $200.00 charge is reasonable in our area.

A third option is to file a complaint with the Washington State Insurance Commissioner’s office and ask them to investigate the insurer’s conduct in refusing to pay the doctor’s narrative report charge.

Scenario #2

A patient was involved in an automobile accident but was on the job at the time. Who is supposed to pay for the treatment: the automobile insurer or the Department of Labor and Industries? If the Department of Labor and Industries is responsible for the treatment bills, does the provider have to write off the difference between his normal charge and what DLI allows, or does the third-party liability insurer pay the difference at the conclusion of the case?

Answer: Since it was an on-the-job injury, the Department of Labor and Industries insurance is primary and responsible for payment of treatment bills. Whenever the Department of Labor and Industries pays a reduced amount from the amount charged, the health care provider cannot bill the patient, third party insurer, or attorney for the difference. WAC 296-20-010(5) states:

When a claim has been accepted by the department of self-insurer, no provider of his/her representative may bill the worker for the difference between the allowable fee and the usual and customary charge. Nor can the worker be charged a fee, either for interest or completion of forms, related to services rendered for the industrial injury or condition.
Refer to chapter 51.04 RCW.

However, because the standard used by DLI requires only that the patient “return to work” and tort laws (the third-party standard) allow the patient to seek treatment until “returned to pre-accident condition,” the provider may request reimbursement for visits beyond the treatment cutoff date imposed by DLI.

Scenario #3

A health care provider is treating a patient involved in three separate motor vehicle accidents. The health care provider has a thick file for the treatment related to each accident. An attorney represents the doctor’s patient, but only for two of the three accidents. The attorney sent a written request to the doctor for copies of all three files. The health care provider called the attorney and advised that is was going to be expensive to copy all the records, but the attorney insisted that copies be made of all three files and agreed to promptly remit payment of the bill. The health care provider copied the records, sent them to the attorney, and submitted a bill for copying the records. The health care provider charged a $16.00 administrative fee for each of the three files plus an appropriate per-page amount. The attorney says that the provider may charge only one clerical fee per patient per request.

Answer: The attorney is correct. A provider is limited to only one $16.00 clerical/administrative fee for copying a patient’s records, regardless of the number of files involved. However, the duplication rate of 69¢ for the first thirty pages and 53¢ for each page thereafter still applies to the total number pages, just as if they were all in one file.

Scenario #4

The PIP adjuster states that he does not have to pay for chart notes from a health care provider treating one of their insureds, and the provider is required to send those records each time a bill is submitted.

Answer: Neither one of these statements is true. Practically speaking, however, some providers advise us that sending chart notes expedites payment of the treatment bill.

Moreover, any patient, attorney, health care insurer, or automobile insurer requesting records from a health care provider is governed by the Uniform Health Care Information Act which allows a maximum charge of $16.00 for clerical searching and handling, plus a maximum 69¢ per page for the first thirty pages of records and a maximum 53¢ per page after the thirtieth page. Washington Administrative Code 246-08-400 governs this. Any health care insurer or automobile insurer claiming that the doctor is responsible for providing records in order to have their bill paid should put that position in writing and send it to the provider. The provider should also ask for a copy of the law or insurance policy upon which this position is based. If the problem persists with a specific adjuster, request the name of the adjuster’s supervisor and discuss the matter directly with him or her. If this provides no relief, the matter should be reported to the Washington State Insurance Commissioner’s office.

I hope this article helps many of you through the daily “challenges” of handling personal injury claims. Usually, laws are already in place that regulate many insurance company practices with which health care providers struggle. Sharing information is the key. We consider it a privilege to represent your personal injury patients, and will continue to work with you to ensure just results.