found in out-of-state policies or when your patient is driving a business or company car at the time of the collision that is covered under a fleet insurance policy. Med pay differs from PIP in that it covers medical payments only (no wage loss or essential services), and it often has minimal medical coverage of $5,000 or less. The same reasonable, necessary, and related to the collision standard still applies for billing.
Health Insurance Coverage If your patient has no PIP coverage available to them, or when PIP medical payments coverage exhausts, then health insurance coverage becomes the primary source for first-party insurance coverage. You should always bill health insurance when it applies, particularly if you are a contracted in-network provider. You will need to review your contract with the health insurance carrier to determine the number of visits that will be covered, what referrals for care may be needed, and what deductibles or co-pays the patient may be responsible for. You will often not receive 100% of your billed charge as you may have contract discounts or write-offs that apply.
Health insurance typically applies a medical necessity determination pursuant to Washington Administrative Code (WAC) 284-43-5440 in processing bills for payment. The medical necessity determination process may include, but is not limited to, evaluation of the effectiveness and benefit of a service for the individual patient based on scientific evidence considerations, up-to-date and consistent professional standards of care, convincing expert opinion and a comparison to alternative interventions, including no interventions. Cost effectiveness may be one of but not the sole criteria for determining medical necessity.
Workers’ Compensation
If your patient is driving a personal or work car and they are in the course of employment while driving (such as driving from one work related sales call to another) then workers’ compensation becomes the primary source for first-party insurance coverage. Workers’ compensation in Washington is usually offered through the Department of Labor & Industries but may also be offered through various self-insured entities if the employer purchased private workers’ compensation coverage. Rules for these claims are codified in Chapter 51 of Revised Code of Washington (RCW) and in Chapter 296 of the Washington Administrative Code (WAC).
Any “worker” (RCW 51.08.180) who sustains an “injury” (RCW 51.08.100) while “acting in the course of employment” (RCW 51.08.013) and makes a timely application (one year from the date or a traumatic injury) to the Department of Labor and Industries (RCW 51.28.020, .050 and .055) is entitled
to workers’ compensation benefits unless they are subject to statutory exclusion (RCW 51.32.020).
Benefits available to your patient include coverage for medical treatment, wage loss or loss of earning power, vocational retraining, permanent partial disability, and in significant injury cases, a pension.
Bodily Injury Liability Coverage
Bodily injury liability insurance is third-party insurance coverage purchased by or legally bound to cover the at-fault party, subject to liability policy limits, when they cause bodily injury to another person. Minimum liability limits in Washington are $25,000 for any one person, up to a total of $50,000 for all claimants in one collision. There are no contractual duties owed by the liability insurance company to your patient, and the third-party adjuster is never your patient’s friend. A liability adjuster wants to settle your patient’s claim quickly and for as little as possible.
If there is no PIP available to your patient, do not bill the third-party expecting payment as treatment pro- gresses. Payment from a third-party claim does not occur until the case
settles. The time allowed to settle such a claim is generally three years in Washington, as mentioned above, but can be shorter. The three-year statute of limitations can be extended by filing a lawsuit.
Uninsured and Underinsured Motorist Claims Just as with PIP, carrying Uninsured Motorist (UM)/Underinsured Motorist (UIM) in Washington is not mandatory, but it must be offered and rejected in writing or electronically. Minimum UM/ UIM coverage is $25,000 per person up to a maximum for all claimants of $50,000. If your patient has PIP, they likely have UM/ UIM. UM coverage applies when the at-fault driver lacks ANY liability coverage. UM “steps into the shoes” of the at-fault person and in effect becomes their insurance. UIM coverage applies when the at-fault driver lacks ENOUGH liability coverage. UIM is stacked on top of the liability coverage for the at-fault driver.
Understanding insurance is essential to your personal injury patient practice. Learn more at:
www.glpattorneys.com, visit the Provider Resources page at:
https://glpattorneys.com/provider- resources/ and view the GLP complimentary 2024 Seminar Series for a chance to network with your peers and learn how to better manage your personal practice:
https://glpattorneys.com/ healthcare-provider-seminar-registration/
—GLP Attorneys is with you and your patients from injury to recovery. In addition to the Provider Resources page on their website, the firm has 10 staffed offices and 36 attorneys in Washington State. They are pleased to be a resource for you and your staff; an attorney is always available to talk to you.
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