13 Fla. L. Weekly Supp. 1154a
Insurance — Personal injury protection — Coverage — Medical benefits — Expert neurological consultation — Usual and customary charges — Evidence — Error to permit insurer’s witness to give opinions as a billing expert although he admitted during testimony that he was not a billing expert and did not do his own billing — Jury could have used this improper testimony in arriving at their verdict — Because of this testimony, it was also error to prohibit provider’s billing specialist from testifying as to codes and fee guide — Provider also should have been allowed to introduce redacted explanation of benefits statements showing amounts insurer had previously paid for the same service — New trial required
HEALTH CARE ASSOCIATES OF SOUTH FLORIDA, INC. (as Assignee of Zuleida Martin), Appellant, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Appellee. Circuit Court, 11th Judicial Circuit (Appellate) in and for Miami-Dade County. Case No. 05-288 AP. L.C. Case No. 02-576 CC 05. September 28, 2006. An appeal from the County Court, Shelley Kravitz, Judge. Counsel: Virginia M. Best, for Appellant. Douglas H. Stein, for Appellee.
(BEFORE STANFORD BLAKE, GILL S. FREEMAN, and VICTORIA SIGLER, JJ.)
(BLAKE, J.) Zuleda Martin was involved in an automobile accident on November 28, 2000. She sought medical treatment at Miami Medical Group under the care of Dr. Jose Vazquez. Dr. Vasquez referred Martin to Health Care for a neurological consultation. Martin was evaluated by Dr. Jose Marquez, an independent contractor, who is paid $125.00 per patient at the time he provides the neurological consultation. The total cost of the expert consultation was $475.00. Progressive reduced the bill to $249.00, without providing an explanation why. Martin assigned her benefits to Health Care, who brought this instant action.
At trial, Dr. Marquez testified that he is a neurologist and neurophysiologist and that he is an independent contractor for Health Care Associates. Dr. Marquez explained his findings as to Martin. He further testified that the charge of $475.00 for the neurological consultation was reasonable in sum and quite typical compared to what other physicians and medical facilities charge. Based on his knowledge as a consultant for over 14 years, usual and customary charges for a consultation by a specialist range from $450.00 to $500.00. He does not fill out the HCFA form, but tells the billing specialist, Rosario Nowak, about the time he spent, the diagnosis, the complexity and the services rendered to enable Nowak to render a bill.
Raphael Cuadros, Progressive’s Litigation Specialist testified that for the most part, he was ignorant as to how charges were determined. Progressive was using a billing service called Clients Quoting Solutions (CQS) which would come up with the amount deemed reasonable.
Rosario Nowak testified that she is the owner, office manager, records custodian, and billing clerk for Health Care Associates. She personally filled out the HCFA form and has been filling out these forms since their inception. She explained the form and the charges thereon. She has attended three seminars on how to properly utilize CPT codes. She attempted to explain the CPT codes and the guidelines for each but was precluded from testifying about the guidelines.
Dr. Allen Hershkowitz testified on behalf of Progressive. Dr. Hershkowitz, who does not do his own billing, testified about what he thought was reasonable and testified as to the range of fees for Medicare, Worker’s Compensation, and HMO’s. He never saw Martin or treated her. He testified that when billing Progressive for a patient that is their insured, he goes by whatever the code is and the time he spent. He testified that he is not a billing expert and does not know if insurance companies pay more.
While Appellant raises several issues, we find one issue dispositive. It was error for the trial court to allow Dr. Hershkowitz to give “opinions” as a billing expert even though he admitted during his testimony that he was not a billing expert and does not do his own billing. The jury could have used this “improper expert opinion” in arriving at their verdict. Because of this testimony, it was also error to prohibit Nowak from testifying as to the codes and the fee guide. Appellant also should have been allowed to introduce redacted EOB statements that showed that Progressive paid $475.00 for the same service.
The combination of Dr. Hershkowitz’s testimony, along with the restrictions on Nowak’s testimony, created an uneven playing field and constitutes reversible error.
REVERSED and remanded to the trial court for a new trial.
