What is a Peer Review and why isn’t my Auto Insurance paying my Medical Bills?

Peer Review of Medical Bills under Act 6What is a Peer Review?

In Pennsylvania, your automobile insurance provides medical coverage to pay your medical bills for medical treatment for injuries sustained in car accidents. Generally, your car insurance company is obligated to pay all bills for treatment which is reasonable and necessary. It is not necessary that you get pre-authorization for treatment. It is your carrier’s responsibility to object to bills it considers unreasonable or unnecessary. Medical bills which are not paid within 30 days are subject to penalties under the Motor Vehicle Financial Responsibility Law (MVFRL). When an auto insurance company wishes to contest the bills submitted by treatment providers, it will send them out for a Peer Review.

An insurance carrier can challenge bills by Peer Review for up to 90 days prior to the challenge. The regulations require that the carrier send the challenged bills with supportive records to an authorized PRO (Peer Review Organization). This is an entity which has been approved by the Insurance Commissioner for this purpose. Bills which deal with particular treatment can only be peer reviewed by an entity in the same specialty. For instance, chiropractic bills can only be reviewed by a chiropractor. The peer reviewer does not see the patient for an examination. His job is to simply review the records and bills, and in accordance with accepted norms and guidelines, render an opinion as to whether treatment is reasonable and necessary. The reviewer does not even have to contact your doctor.

What should I do after a Peer Review?

Over 80% of Peer Reviews are unfavorable, in whole or in part to the patient. If your bills are peer reviewed, and the review is unfavorable, the report will advise you as to your appeal rights. Probably the worst strategy is to appeal an unfavorable Peer Review. Reconsiderations of peer reviews are also over 80% unfavorable to insureds and the loser of the appeal has to pay the fees (usually $450.00-$500.00). Insureds also have the right to file suit against their own insurance company immediately. There are numerous regulations which have been promulgated to protect insureds. Many of these are ignored or abused by carriers.

Do I need a lawyer if my bills have been the subject of a Peer Review?

To protect your rights in an automobile accident claim, it is always prudent to hire a lawyer as soon as possible after you have been involved in an accident. It is even more important to seek and retain counsel whenever an insured receives notice that his/her bills are being peer reviewed. Failing to challenge your carrier for refusal to pay appropriate bills can affect your treatment and affect your claim against the at-fault driver. Call our office today for a free consultation.

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