PIP 14-Day Rule, “Emergency Medical Condition” explained

Posted on: October 22, 2015

This is for physicians who may have this question. Clients often contacting us about documentation for an “emergency medical condition” (“EMC”) and also ask about the 14 day rule in PIP.

Q: Should an “emergency medical condition” (“EMC”) be documented in your patient’s records if the Patient went to the emergency room before coming to your office? 

A: YES!

If you are legally allowed to diagnose an EMC (if you are a licensed M.D., D.O., D.M.D., D.D.S., P.A. or A.R.N.P.), you have the ability to decide if a patient has what qualifies as an “emergency medical condition.” If you find that the patient has an EMC, document it in the patient’s chart and your billing.  Unfortunately, it is our experience that the automobile insurance carriers are taking a position that even if a person goes to the emergency room, that visit does not automatically mean there is an emergency medical condition.

  • We are fighting the carriers on the EMC issue, as we take the position that the law says a treating physician (i.e. YOU, if you are a licensed M.D., D.O., D.M.D., D.D.S., P.A. or A.R.N.P.) has to say there is NO emergency medical condition to cut off benefits at $2,500.00.
  • Carriers are taking the position that for a patient to receive the full $10,000.00 benefit, there must be a positive declaration of an emergency medical condition.  While we disagree with the carriers’ position, if there are notes in your patients’ records indicating that you have found an emergency medical condition as defined by the statute, it takes this argument away from the carriers.

Q: Some doctors have asked us if they must determine the EMC within 14 days of an automobile crash. 

A: NO!

An EMC finding does not have to be made within the initial 14 day period.  The patient must receive medical treatment within the initial 14 day period.

The physicians a patient can consult with for initial treatment are more expansive than the physicians who can render an EMC opinion (the biggest group are the Chiropractic physicians, whose initial care within 14 days qualifies, but who cannot render EMC opinions).  If the patient does not receive medical treatment within 14 days, the carriers can (and do) refuse to provide any benefits.

Thank you for showing your faith in our firm.  If you all have additional questions, please do not hesitate to contact any of the lawyers here directly.

Author: FLLegalGroup
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