13 Fla. L. Weekly Supp. 1088c
Insurance — Personal injury protection — Discovery — Computer database used to reduce bills — If insurer intends to rely on computer database in defending reduction of bills claimed to exceed usual, customary and reasonable amounts, insurer must produce materials regarding use, composition, operation, and maintenance of database
NADAL MEDICAL CENTER, INC. (as assignee of Yusdey Estevez), Plaintiff, v. DAIRYLAND INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Small Claims Division. Case No. 05 31413, Division J. August 24, 2006. Gaston J. Fernandez, Judge. Counsel: Timothy A. Patrick, for Plaintiff. James Bogos, for Defendant.
[Editor’s note: See 15 Fla. L. Weekly supp. 787a.]
ORDER ON PLAINTIFF’S MOTION TO COMPEL BETTER RESPONSES TO PLAINTIFF’S 3RD REQUEST TO PRODUCE
This cause having come before the Court on August 14, 2006, on Plaintiff’s Motion to Compel Better Responses to 3rd Request to Produce, with Timothy A. Patrick, Esquire appearing on behalf of Plaintiff and James Bogos, Esquire appearing on behalf of Defendant, and the Court, being fully advised in the premises, rulesthat for the reasons stated on the record and recorded in open court, which constitutes the decision of this Court,
ORDERS AS FOLLOWS:
If the Defendant intends to rely upon the Mitchell Medical database as a defense in this case, it must produce the materials requested below by the Plaintiff:
1. Any and all documents in the possession of Defendant that indicate or tend to prove that the amount billed by Plaintiff for health care services rendered exceeded the usual, customary, and reasonable amount forsuch services within the geographic region in which the services were rendered.
2. All guidelines, policies, procedures, or protocols, that Defendant followed or adhered to, or otherwise used in determining that the amount billed by Plaintiff for health care services exceeded the usual, customary, and reasonable amount for such services within the geographic region in which the services were rendered.
3. Any manuals, guidelines, office policies, practices, procedures, computer programs or other documents, programs, memoranda or notes, whether in print or other form, including electronic medium of anytype, regarding the computer databases used to determine the reasonableness of charges or medical necessity of health care services provided by Plaintiff.
4. Any manuals, guidelines, office policies, practices, procedures, computer programs, or other documents, programs, memoranda or notes, whether in printed or other form, including electronic medium of any type, regarding the computer database used to determine the regional charges for health care services provided to personal injury protection claimants.
5. Any and all authorities, seminar notes, documents, notes, memoranda, governmental data, Health Care Finance Administration data, or electronic data utilized in the development and maintenance of the statistical model used to determine the appropriate or reasonable charge for health care services provided to personal injury protection claimants, including the process for creating the statistical model; the composition, and results, of any survey(s) used to create the statistical model; and the basis of, or guidelines for, determining orcreating the geographical boundaries of any regions used to determine the amount of fees to be paid to any health care providers for services rendered to personal injury protection claimants.
6. Any and all documentation, correspondence, memoranda, brochures, audio or video tapes, or electronic medium regarding the factual basis by which Defendant created or procured the computer program it used to make a determination as to the reasonableness of the cost and/or medical necessity of health care services provided by Plaintiff, including the number of and type of health care providers that form the basis for the statistical model used, the specific boundaries of the geographic region, and the training and qualifications of medical providers included in the survey or statistical model.
7. If any claims data used to determine the reasonableness of the cost of any health care service provided by Plaintiff is acquired through any data contribution program that includes any insurers, medical providers, or provider billing services, provide a copy of any contracts, guidelines, reporting procedures, information verification procedures and/or any other documents, notes, memoranda or items regulating or describing how this information is reported or collected and identifying those persons or entities participating in the data contribution program.
8. Any and all documents, notes, manuals, guidelines or procedural manuals showing how any information gathered from HCFA, CHAMPUS, Medicare, Medicaid, and/or any workers compensation carriers was used, either directly or indirectly, in determining the reasonableness of the cost of any health care service provided by Plaintiff.
9. The specific zip codes included in the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed.
10. The specific CPT codes included in the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed.
11. The exact identity of each and every health care and/or diagnostic service provider whose charges areused in the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed.
12. The exact prevailing charge data percentile array used in the database used to decide the health care services provided by Plaintiff would not be paid at the rate billed.
13. The exact data composition of the database used to decide the health care services provided by Plaintiff would not be paid at the rate billed, and whether the following data is included in the database: Medicaid, Medicare, state worker’s compensation rates, state managed under-insured risk pools, CHAMPUS, health maintenanceand preferred provider organizations, self-funded employee benefit plans, traditional indemnity insurers and any and all other datautilized.
14. Any and all documentation, correspondence, memoranda, brochures, audio orvideo tapes, or electronic medium indicating whether or not the relative value scale (RVS”) is incorporated into the database used to decide that the health careservices provided by Plaintiff would not be paid at the rate billed.
15. Any and all documentation, correspondence, memoranda, brochures, audio or video tapes, or electronic medium indicating whether or not the “RBRVS” (Medicare venture) is incorporated into the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed.
16. Any and all documentation, correspondence, memoranda, brochures, audio or video tapes, or electronic medium indicating whether simple statistical profiling of charges in a geographic area by procedure code is incorporated into the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed.
17. The conversion factor employed if an “RVS” methodology is incorporated into the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed.
18. The maintenance schedule of the database used to decide that the health care services provided by Plaintiff would not be paid at the rate billed, including but not limited to whether or not a “moving window” is employed and how often a new release of the database was produced during the twelve month period prior to the date Plaintiff’s charges were analyzed.
19. The “regional inflation factors,” if any incorporated into the database usedto decide that the health care services provided by Plaintiff would notbe paid at the rate billed.
* * *
