12 Fla. L. Weekly Supp. 678b
Insurance — Personal injury protection — Explanation of benefits — Failure to provide requested information — Where medical provider failed to provide additional information requested in EOBs issued within 30 days of insurer’s receipt of bills, bills never became overdue, and insurer is relieved of duty to pay PIP benefits
RICHARD POMELLA, D.C., d/b/a TOTAL HEALTH CARE (Patient: Steven Boncamper), Plaintiff, vs. PROGRESSIVE BAYSIDE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 02-013111 (54). March 16, 2005. Lisa Trachman, Judge. Counsel: Charles Glen Ged, for Plaintiff. Chad L. Christensen, Barnett & Barnard, P.A., Hollywood, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE having come before the Court on February 14, 2005, upon the Defendant’s Motion for Partial Summary Judgment, and this Court having heard argument of counsel and having been otherwise fully advised in the premises, the Court hereby finds as follows:
1. The plaintiff filed suit against Progressive for personal injury protection benefits pursuant to Florida Statute § 627.736.
2. Stanford Boncamper was involved in an automobile accident on January 25, 2002. Mr. Boncamper made a claim for PIP benefits under an insurance policy issued by Progressive.
3. Subsequent to the automobile accident, Mr. Boncamper received medical treatment and/or services from the plaintiff from February 1, 2002-July 23, 2002.
4. Utilizing the Physicians’ Current Procedural Terminology, plaintiff billed CPT code 97110 on 2/4/02, 2/13/02, 2/27/02, 3/13/02, 3/18/02, 3/20/02, and 3/22/02. CPT code 97110 is a “therapeutic procedure, one or more areas, each 15 minutes; and therapeutic exercises to develop strength and endurance, range of motion, and flexibility.”
5. Progressive provided an “Explanation of Benefits” (EOB) to the plaintiff addressing the plaintiff’s charge for each of the above dates of service. The EOBs request the plaintiff to describe the techniques and tasks used in the performance of therapeutic exercises on the patient. Each of the EOBs were provided to plaintiff within thirty (30) days of Progressive’s receipt of plaintiff’s bill.
6. Plaintiff did not provide the requested information for CPT code 97110 prior to the filing of this lawsuit.
7. Utilizing the Physicians’ Current Procedural Terminology, plaintiff billed CPT code 97032 on 2/11/02, 3/4/02, 3/11/02, 3/15/02, 3/25/02, 4/1/02, and 4/9/02.
8. CPT Code 97032 is the application of electrical simulation that requires direct (one-on-one) patient contact by the provider.
9. Progressive provided an “Explanation of Benefits” (EOB) to the plaintiff addressing the plaintiff’s charges for each of the above dates of service. The EOBs advise the plaintiff that the medical notes do not correspond to the CPT code billed and requested the plaintiff to provide a letter if manual muscle stimulation was performed for reconsideration.
10. Plaintiff did not provide a letter to Progressive prior to the filing of this lawsuit stating that manual muscle stimulation was performed on each of the above dates of service.
11. Utilizing the Physicians’ Current Procedural Terminology, plaintiff billed CPT code 95851 at two (2) units on 2/27/02. CPT code 95851 is for Range of Motion measurements and report; each extremity or each trunk section.
12. Progressive provided an “Explanation of Benefits” (EOB) to the plaintiff within thirty (30) days of receipt of plaintiff’s bill addressing the plaintiff’s charge for CPT code 95851. Progressive requested the plaintiff to provide a report in order to determine the reasonable expenses owed.
13. Plaintiff did not provide a report for CPT code 95851 prior to the filing of this lawsuit.
14. Utilizing the Physicians’ Current Procedural Terminology, plaintiff billed CPT code 95831 at two (2) units on 3/1/02. CPT code 95831 is for muscle testing manual with a report; extremity or trunk.
15. Progressive provided an “Explanation of Benefits” (EOB) to the plaintiff within thirty (30) days of receipt of plaintiff’s bill addressing the plaintiff’s charge for CPT code 95831. Progressive advised the plaintiff that a report was not provided and requested the plaintiff to provide a report in order to determine the reasonable expenses owed.
16. Plaintiff did not provide a report for CPT code 95831 prior to the filing of this lawsuit.
17. Florida Statute 627.736(6)(b) allows an insurer to discover facts from medical providers about medical services provided to an insured. This section provides:
Every physician, hospital, clinic, or other medical institution providing, before or after bodily injury upon which a claim for personal injury protection insurance benefits is based, any products, services, or accommodations in relation to that or any other injury, or in relation to a condition claimed to be connected with that or any other injury, shall, if requested to do so by the insurer against whom the claim has been made, furnish forthwith a written report of the history, condition, treatment, dates, and costs of such treatment of the injured person and why the items identified by the insurer were reasonable in amount and medically necessary, together with a sworn statement that the treatment or services rendered were reasonable and necessary with respect to the bodily injury sustained and identifying which portion of the expenses for such treatment or services was incurred as a result of such bodily injury, and produce forthwith, and permit the inspection and copying of, his or her or its records regarding such history, condition, treatment, dates, and costs of treatment. . . . .
If an insurer makes a written request for documentation or information under this paragraph within 30 days after having received notice of the amount of a covered loss under paragraph 4(a), the amount or the partial amount which is the subject of the insurer’s inquiry shall become overdue if the insurer does not pay in accordance with paragraph 4(b) or within 10 days after the insurer’s receipt of the requested documentation or information, whichever occurs later.
18. Florida Statute 627.736(6)(b) requires a provider to directly respond to timely requests for more information or documentation.
19. As a result of plaintiff’s failure to provide additional information regarding the treatment provided to Mr. Boncamper, plaintiff’s medical bills for these services never became overdue and Progressive is relieved of its duty to pay PIP benefits to Plaintiff under Florida Statute §627.736(4)(b).
IT IS THEREFORE ORDERED AND ADJUDGED that Defendant’s Motion for Partial Summary Judgment is Granted.
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