13 Fla. L. Weekly Supp. 912b
Insurance — Personal injury protection — Coverage — Medical expenses — MRI — Allowable amount — Adjustment to Consumer Price Index for All Urban Consumers in South Region — Calculation — CPI calculation must be made annually and cumulatively, reflecting combined prior years’ increases from 2001 through August 1 of year MRI was performed — Correct CPI adjustment calculation reveals insurer paid medical provider less than allowable amount for MRI
NATIONAL NUCLEAR CENTER, INC. d/b/a HOLLYWOOD DIAGNOSTICS CENTER, INC. (a/a/o Linda Chin), Plaintiff, vs. PROGRESSIVE AUTO PRO INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 05-11430 COCE 53. June 30, 2006. Robert W. Lee, Judge. Counsel: Kathy Eikosidekas, Marks & Fleischer, P.A., Fort Lauderdale, for Plaintiff. Maury L. Udell, Miami, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR FINAL SUMMARY JUDGMENT
THIS CAUSE having come before the Court on June 23, 2006 for hearing of the Plaintiff’s Motion for Final Summary Judgment, and the Court’s having reviewed the Motion and entire Court file; heard argument; reviewed the relevant legal authorities; and been sufficiently advised in the premises, the Court finds as follows:
Background. The Plaintiff filed its Amended Complaint seeking declaratory relief, alleging that the Defendant has improperly applied the price adjustment set forth in Fla. Stat. §627.736(5)(b)(5). More specifically, the Plaintiff asserts that the Defendant has miscalculated the allowable amount by not adjusting the base reimbursement amount annually to reflect the prior calendar years’ changes in the annual medical care item of the Consumer Price Index for All Urban Consumers in the South Region as determined by the Bureau of Labor Statistics.
Conclusions of Law. Summary judgment is appropriate when the pleadings, depositions, answers to interrogatories, admissions on file, and affidavits conclusively show that there remain no genuine issues of material fact and the moving party is entitled to judgment as a matter of law. Fla. R. Civ. P. 1.510.
The burden is on the moving party to establish the non-existence of any genuine issue of material fact. Romero v. All Claims Insurance Repairs, Inc., 698 So.2d 605, 606 (Fla. 3d DCA 1997). In determining that no issue of material fact exists, the trial court may rely upon exhibits, affidavits and pleadings on file. See Mack v. Commercial Industrial Park, Inc., 541 So.2d 800, 800 (Fla. 4th DCA 1989). Once the movant tenders competent evidence to support the motion, the party against whom judgment is sought must present contrary evidence to reveal a genuine issue. It is not enough for the party opposing summary judgment merely to assert that an issue exists. Buitrago v. Rohr, 672 So.2d 646, 648 (Fla. 4th DCA 1996). The issue for the Court is whether the pleadings on file and record evidence establish that the payment made by the Defendant included the full amount due under the CPI adjustment. In this case, the pleadings on file and record evidence submitted herewith demonstrates conclusively that no genuine issue of material fact exists on this issue.
The pertinent part of Fla. Stat. §627.736(5)(b)(5) governing price controls on magnetic resonance imaging services provides:
“Allowable amounts that may be charged to a personal injury protection insurance insurer and insured for magnetic resonance imaging services shall not exceed 175 percent of the allowable amount under the participating physician fee schedule of Medicare Part B for year 2001, for the area in which the treatment was rendered, adjusted annually on August 1 to reflect the prior calendar year’s changes in the annual Medical Care Item of the Consumer Price Index for All Urban Consumers in the South Region as determined by the Bureau of Labor Statistics of the United States Department of Labor for the 12-month period ending June 30 of that year . . .” (emphasis added).
2. Based on the clear language of the statute, the proper frequency of the CPI calculation is annually and cumulatively so that the fee schedule amount for the year in question reflects the combined prior year’s increases from 2001 through August 1st of the year in which the MRI diagnostic service is performed, reflecting the percentage in change of prices for the 12-month period ending June 30 of that year. The first adjustment occurred on August 1, 2002. This adjustment reflected the percentage in change of prices between June 30, 2001 and June 30, 2002.
3. Based on the clear language of the statute, the proper percentage increases and time periods are 4.1% for services rendered from August 1, 2002 to July 31, 2003; and 4.0% for services rendered from August 1, 2003 to July 31, 2004. This is based on the undisputed CPI figures as required by the statute.
4. As pertains to the instant case, the 2001 Medicare Part B fee schedule amount for a Lumbar MRI (CPT 72148) at issue in this case performed in Region 3 is undisputably $609.44. For an unaccredited facility, 175% of that amount is $1,066.52, and PIP would then pay 80% of that amount for an MRI performed prior to August 1, 2002. It is similarly undisputed that the Plaintiff is an unaccredited facility.
For that same MRI performed the following year, between August 1, 2002 and July 31, 2003, the fee schedule amount is $1,110.25 as seen in the following equation: [$1,066.52 + CPI of 4.1%] = $1,110.25.
For that same MRI performed the following year, between August 1, 2003 and July 31, 2004, the fee schedule amount is $1,154.66 as seen in the following equation: [$1,066.52 + CPI of 4.1% + CPI of 4.0%] = $1,154.66.
5. As a result of the foregoing, the correct amount for the subject MRI in this case, CPT Code 72148 performed on April 17, 2004 in the Region of Broward County is $1,154.66.
6. It is undisputed that the Defendant paid only $1,112.38, leaving a balance due the Plaintiff under the correct CPI adjustment calculation.
7. As this ruling moots the Defendant’s Motion for Summary Judgment, the hearing set for July 17, 2006 at 10:30 a.m. is hereby canceled.
8. The Court reserves jurisdiction to consider the issue of attorney’s fees and costs.
