13 Fla. L. Weekly Supp. 1097a
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 and percentage in change of prices for 12-month period ending June 30 of that year — Correct CPI adjustment calculation reveals insurer paid medical provider less than allowable amount for MRI
ONE STOP MEDICAL, INC., (Burnitt Johnson), Plaintiff(s), vs. PROGRESSIVE AUTO PRO INSURANCE CO., Defendant(s). County Court, 17th Judicial Circuit in and for Broward County. Case No. 05-012670 COCE 52. May 15, 2006. Jay S. Spechler, Judge. Counsel: Gary Marks, Marks & Fleischer P.A., Fort Lauderdale. Maury Udell.
ORDER GRANTING PLAINTIFF’S MOTION FOR FINAL SUMMARY JUDGMENT
This cause came before the Court on April 25, 2006 for hearing of the Plaintiff’s Motion for 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, finds as follows:
I. BACKGROUND
The Plaintiff filed a one count Complaint seeking a declaratory judgment ruling as to:
a) The method of calculating the fee schedule amount for MRI scans pursuant to Florida Statute 627.736(5)(b)(5), whether the calculation is annually and cumulative and the dates when the adjustment is applied;
b) The actual number the fee schedule provides and the time periods; and
c) The actual fee schedule amount which an unaccredited MRI provider is entitled to be reimbursed for CPT Code 72141, date of service May 4, 2005 in the Region of Broward County.
II. FACTS
The following facts are undisputed: Defendant, PROGRESSIVE AUTO PRO INSURANCE CO., insured Burnitt Johnson under an 80% policy which provided PIP benefits in accordance with Florida Law. Plaintiff performed a Cervical MRI CPT Code 72141, on May 4, 2005 on the insured, Burnitt Johnson resulting from an automobile accident that occurred on April 1, 2005. Defendant, PROGRESSIVE AUTO PRO INSURANCE CO., was given timely notice of the bill for the amount of $1,850.00. On July 14, 2005, Plaintiff demanded payment. Defendant denied any further obligation and instead, asserted that it had already reimbursed the Plaintiff at the maximum allowable amount pursuant to Florida Statute § 627.736(5) in the amount of $827.44 (80% of $1,030.96) plus $9.02 in interest.
Plaintiff argues that Defendant’s calculations incorrectly apply the Consumer Price Index as instructed by Florida Statute § 627.736(5)(b)(5). Plaintiff argues Defendant’s calculation incorrectly computes $1,030.96 as the allowable amount a medical provider may collect for an MRI, CPT Code 72141, performed on May 4, 2005. Plaintiff argues that the correct application of the statute in conjunction with the CPI realizes $1,116.16 as the allowable amount that a medical provider may charge for the subject MRI performed between August 1, 2004 and July 31, 2005. This Court agrees.
III. 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).
IV. RULING
The pertinent part of Florida Statute 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. . .”
1. 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 1 of the year in which the MRI scan is performed, reflecting the percentage in change of prices for the 12-month period ending June 30th of that year. The first adjustment occurred on August 1st, 2002. This adjustment reflected the percentage in change of prices between June 30th, 2001 and June 30th, 2002.
2. Based on the clear language of the statute, the proper percentage increases and time periods are 4.1% for services rendered after August 1st, 2002 but before August 1st, 2003; 4.0% for services rendered after August lst, 2003 but before August 1st, 2004; and 4.4% for services rendered after August 1st, 2004 but before August 1st, 2005.
3. To illustrate, the 2001 Medicare Part B fee schedule amount for a Cervical MRI (CPT 72141) at issue in this case performed in Region 3 is $564.29. For an unaccredited facility, 175% of that amount is $987.51, and PIP would then pay 80% of that amount for an MRI performed prior to August 1, 2002.
For that same MRI performed the following year, between 8/1/02 and 7/31/03, the fee schedule amount is $1028.00 as seen in the following equation: [$987.51 + CPI of 4.1%] = $1028.00.
For that same MRI performed the following year, between 8/1/03 and 7/31/04, the fee schedule amount is $1069.12 as seen in the following equation: [$987.51 + CPI of 4.1% + CPI of 4.0%] = $1069.12.
For that same MRI performed the following year, between 8/1/04 and 7/31/05, the fee schedule amount is $1116.16 asseen in the following equation: [$987.51 + CPI of 4.1% + CPI of 4.0%+ CPI of 4.4%] = $1116.16.
4. As a result of the foregoing, the correct amount for the subject MRI in this case, CPT Code 72141 performed on May 4, 2005 in the Region of Broward County is $1,116.16.
ORDERED AND ADJUDGED that Plaintiff’s Motion for Final Summary Judgment is hereby GRANTED.
