Can PIP Insurers Apply Medicare Coding Policies?

  • Can PIP Insurers Apply Medicare Reductions?
  • Can PIP Insurers Apply OPPS Reductions?
  • Can PIP Insurers Apply NCCI Reductions?
  • Can PIP Insurers Apply MPPR Reductions?

The Law:

3. Subparagraph 1. does not allow the insurer to apply any limitation on the number of treatments or other utilization limits that apply under Medicare or workers’ compensation. An insurer that applies the allowable payment limitations of subparagraph 1. must reimburse a provider who lawfully provided care or treatment under the scope of his or her license, regardless of whether such provider is entitled to reimbursement under Medicare due to restrictions or limitations on the types or discipline of health care providers who may be reimbursed for particular procedures or procedure codes. However, subparagraph 1. does not prohibit an insurer from using the Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services, including applicable modifiers, to determine the appropriate amount of reimbursement for medical services, supplies, or care if the coding policy or payment methodology does not constitute a utilization limit. (Emphasis added)

My Interpretation:


MAYBE, first the insurance policy must incorporate these limitations into their policy. Insurers may not take advantage of any reimbursement limitation without specifically electing to do so in the language of their policy. Second, the insurers may only apply medicare coding policies and payment methodologies if they are not a limitation on the number of treatments or a utilization limit! Finally, many of these policies allow reimbursement at amounts below the 2007 Medicare Part B fee schedule and are therefore not allowed under the PIP statute.

Remember That The Insurance Policy Must Allow The Pip Insurer To Apply These Reductions:

  • OPPS means Outpatient Prospective Payment System.
  • NCCI means National Correct Coding Initiative.
  • MPPR means Multiple Procedure Payment Reduction.
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