13 Fla. L. Weekly Supp. 716b
Insurance — Personal injury protection — Coverage — Medical expenses — Denial — Explanation of benefits — EOB stating that bill had been denied because documentation did not fit coding and advising of procedure for seeking reconsideration or recoding constitutes denial of bill, not discovery request that tolled time for payment — Payment made 55 days after receipt of bill was overdue payment for which interest is due
JEFFREY S. BEITLER, MD, P.A. (HILDA STRALEY), Plaintiff, v. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Dade County. Case No. 02-24929 SP 23 (02). May 2, 2006. Caryn Canner Schwartz, Judge. Counsel: Brian Rodier, Rodier & Rodier, P.A. David Bronstein.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT REGARDING UNPAID INTEREST
THIS CAUSE having been presented to the Court on Plaintiff’s motion for summary judgment regarding unpaid interest, having been heard, the Court having heard argument of counsel, having reviewed memoranda and case law submissions by both parties, having considered the Plaintiff’s motion and the Defendant’s Affidavit of Kristine Scarantino, and being otherwise advised in the premises, it is hereupon,
ORDERED and ADJUDGED, that the motion is GRANTED. The court finds as follows:
1. The plaintiff, Jeffrey S. Beitler, M.D., P.A., provided medical treatment to defendant’s insured, Hilda Straley. Ms. Straley assigned her insurance benefits to the plaintiff. The plaintiff filed a motion for summary judgment regarding unpaid interest on a bill plaintiff submitted to defendant, under the personal injury protection benefits portion of his patient’s insurance policy.
The plaintiff conducted a medical evaluation, CPT code 99244, on 7/16/2002, and submitted a bill for that code along with medical records to the defendant. The affidavit of Jeffrey Beitler, M.D., established that the bills along with a three page typewritten medical report were mailed to the defendant on August 6, 2002. The defendant received the bill and records on August 7, 2002. On October 1, 2002, fifty five (55) days after having received the bill, defendant made a payment for CPT code 99244 in the amount of $284.80. The payment was for an amount defendant unilaterally determined was reasonable, but it did not include interest as required section 627.736(4)(c) of the Florida Statutes.
2. The defendant argued that after having received the bill and records on August 7, 2002, it forwarded an Explanation Of Benefits (“EOB”) to the plaintiff on August 26, 2002, and that the notes on the bottom portion of the EOB constituted a 627.736(6)(b) request, thus tolling the time for payment. This court disagrees. The note on the bottom of the EOB that pertained to the bill for code 99244 read:
Based on proper coding per the Physician’s Current Terminology (CPT) it seems that the service you have performed has not fulfilled the requirements of code 99244 based upon the documentation provided. Evaluation and management codes, (E/M codes) require 3 specific components which include the type of the exam, the complexity of the decision made as well as the history obtained at that exam. However, time spent with the patient is the controlling factor when counseling or coordination of care exceeds 50% of the time spent with the patient. Your documentation does not fit the coding of service 99244 which is a 60 minute face to face evaluation per the Physician’s Current Terminology (CPT) and has been denied. If you wish reconsideration of this code, please provide a letter that the provider saw the patient for 60 minutes. If you wish to recode this visit, based on either time or not fulfilling the required components, please present the claim timely pursuant to 627.736 Florida statutes. (Emphasis Added).
3. This court has carefully reviewed the statute and the legislative changes of section 627.736. The face of the EOB unequivocally states that the bill is denied. The Court finds Progressive’s EOB constitutes a 627.736(4)(b) denial of the 99244 charge. The EOB is not a 627.736(6)(b) discovery request. For this reason, the time period in which to make payment was not tolled, and the Defendant’s payment on October 1, 2002, was an overdue payment for which interest is due pursuant to section 627.736(4)(c).
4. The Plaintiff is entitled to interest on the $284.80 defendant paid on October 1, 2002, and judgment for that interest shall be entered in favor of the Plaintiff.
5. The Court reserves jurisdiction over the remaining issues in the case and to determine Plaintiff’s attorney fees and costs.
