Practical Tips regarding Emergency Medical Condition (EMC)
If you are billing PIP insurance since January 2013 then you should know what an EMC is. An emergency medical condition is a vague definition that is actually a legal term and not a medical term. You didn’t miss that day in medical/chiropractic school!
The Florida Legislature came up with the EMC as a way to exclude chiropractors access from automatically getting $10,000 in PIP on each patient. The idea was that only a person who had an EMC would get the $10,000 in coverage and insurance companies would be able to cap benefits at $2,500 for most patients that didn’t have an EMC.
Before the law went into effect, some medical doctor sent a postcard to all the chiropractors in Florida stating that he would give an EMC to every patient. Today, we have this thing called an EMC doctor. The “EMC doctor” is one of those “Florida Man” things that only exists in Florida like alligator wrestling.
If you are a chiropractor referring a patient for an EMC here are some tips:
Chiro Tip- Chiropractors can avoid getting sued by using different EMC doctors on a regular basis. Don’t just use one EMC doctor. The insurance companies will claim that you have a “quid pro quo” relationship with the one EMC doctor. The insurance company will claim that you give the EMC doctor the ability to get paid a lot of money from PIP in exchange for guaranteed access to $7,500 in extra coverage. Don’t be in bed with one EMC doctor.
Chiro Tip- if a company says “EMC” in their name- look elsewhere. Once it hits the fan, you will be grateful for this advice.
Chiro Tip- don’t use MRI companies to provide you an EMC. I have represented multiple chiropractors who have been sued for this reason. The radiologist doesn’t see the patient. Insurance companies consider this a kick back. We know that “hey, send me an MRI and I will give you $200” is an illegal kickback. Insurance companies claim that “hey, send me an MRI and I will give you $7,500 in extra coverage” is an illegal kickback. Do you want to be the doctor to fight a billion dollar company on this issue and see who wins? Do you have $500,000 to spend on legal fees to fight back?
Chiro Tip- make sure your EMC doctor is actually providing a real report. I have seen multiple EMC doctors use the same exact report for every patient. Print up three EMC reports from your doctor and look for patterns. One EMC doctor was misgendering patients before it was a political thing….out of laziness. Another EMC doctor was giving every patient the same exact range of motion. And don’t say “well I don’t control if the EMC doctor does a bad job” because you set them up with the EMC doctor.
If you are a medical provider who provides EMC opinions here are some practical tips:
EMC Doc Tip (1)
Don’t give an EMC to every single patient. Insurance companies keep statistics on this, especially State Farm and Geico. They mention in their lawsuits things like “virtually every patient received an EMC diagnosis” or “out of 482 claims submitted there were 480 EMC’s provided.”
EMC Doc Tip (2)
Don’t provide an EMC to an minor children unless they have objective findings like an MRI or x-ray showing justification- then mention that justification in your report. Giving every 8 year old you see an EMC is going to increase your risk of getting sued.
EMC Doc Tip (3)
Sometimes you have to tell the referring provider “no” to an EMC. If a patient is telling you their biggest complaint is a level 2 pain in their big toe then you should not be giving them an EMC. You need to have a clearly established criteria for when you provide an EMC.
EMC Doc Tip (4)
I would caution anyone from billing a level 4 or 5 exam code when the primary purpose is to diagnose an EMC. This applies to all exams that are not done at a hospital. It is a major red flag to bill level 4 or 5 and I say that because there are many lawsuits from Geico and State Farm against doctors who billed level 4 or 5 exam codes. Oftentimes, the doctors exam is not thorough enough to justify the higher level and/or the patient’s complaints aren’t severe enough to warrant the higher levels. If you want to stay below the radar then bill a level 3- just make sure your written report meets the criteria for a level 3.
EMC Doc Tip (5)
Don’t start billing a bunch of extra codes if you are “just an EMC doctor.” If you are going to play that game then don’t bill State Farm or Geico because they have gone after EMC doctors for this in the past. Many times, insurance companies will label these extra codes unbundling.