14 Fla. L. Weekly Supp. 798b
Insurance — Personal injury protection — 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 MRIs
Al OPEN MRI, INC., as assignee for Kerlyne Baptiste, Plaintiff, vs. ARTISAN AND TRUCKERS CASUALTY COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 06-19905-(52). June 18, 2007. Jay S. Spechler, Judge. Counsel: Glenn E. Siegel, Lesser Lesser Landy and Smith. Maury Udell.
ORDER GRANTING PLAINTIFF’S MOTIONFOR FINAL SUMMARY JUDGMENT
This cause came before the Court on the Plaintiff’s Motion for Final Summary Judgment, and the Court’s having reviewed the Motion and entire Court file, considering the positions of both parties, 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 damages for insufficient payment of no-fault benefits. This case involves the legal argument issue concerning the following:
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 accredited MRI provider is entitled to be reimbursed for CPT Code 72141, date of service July 31, 2006 in the Region of Broward County.
II. FACTS
The following facts are undisputed: Defendant, ARTISAN AND TRUCKERS CASUALTY COMPANY insured Kerlyne Baptiste under an 80% policy which provided PIP benefits in accordance with Florida Law. Plaintiff performed a Cervical MRI CPT Code 72141, and a Lumbar MRI CPT Code 72148 on July 31, 2006 on the claimant, Kerlyne Baptiste, which was a reasonable, related and necessary service resulting from an automobile accident that occurred on May 29, 2006. Defendant, ARTISAN AND TRUCKERS CASUALTY COMPANY was given timely notice of the bill for the amount of $3,700.00. ARTISAN AND TRUCKERS CASUALTY COMPANY initially issued payment for benefits in the amount of $1914.36. On October 13, 2006, Plaintiff demanded additional payment for PIP benefits in the amount of $297.13. Defendant subsequently issued an additional payment in the amount of $218.78 for benefits, leaving a difference in the amount of $74.39. Therefore, in total, the Defendant paid total PIP benefits for the MRI of the cervical spine and the MRI of the lumbar spine in the amount of $2133.14.
Defendant, without objection, adopts the motion for summary judgment and memorandum of law on the CPI issue previously filed by the Defendant in the case currently on appeal in the Fourth DCA, One Stop Medical v. Progressive, Case Number: 05-012670 COCE (52).
Plaintiff argues that Defendant’s calculations incorrectly apply the Consumer Price Index as instructed by Florida Statute § 627.736(5)(b)(5). Plaintiff argues that the correct application of the statute in conjunction with the CPI realizes $1326.63 as the allowable amount for the cervical MRI performed between August 1, 2005 and July 31, 2006. The Plaintiff also argues that the correct application of the statute in conjunction with the CPI realizes $1432.78 as the allowable amount for the lumbar MRI performed between August 1, 2005 and July 31, 2006. 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 1st of the year in which the MRI scan 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 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 1st, 2003 but before August 1st, 2004; 4.4% for services rendered after August 1st, 2004 but before August lst, 2005; and 3.4% for services rendered after August 1st, 2005 but before August 1st, 2006.
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 accredited facility, 200% of that amount is $1128.58, and PIP would then pay 80% of that amount for an MRI performed prior to August 1, 2002, or $902.86.
For that same MRI performed the following year, between 8/1/02 and 7/31/03, the fee schedule amount is $1174.85 as seen in the following equation: [$1128.58 + CPI of 4.1%] = $1174.85.
For that same MRI performed the following year, between 8/1/03 and 7/31/04, the fee schedule amount is $1221.85 as seen in the following equation: [$1128.58 + CPI of 4.1% (+ CPI of 4.0%)] = $1221.85.
For that same MRI performed the following year, between 8/1/04 and 7/31/05, the fee schedule amount is $1275.61 as seen in the following equation: [$1128.58 + CPI of 4.1% (+ CPI of 4.0%) (+ CPI of 4.4%)] = $1275.61.
For that same MRI performed the following year, between 8/1/05 and 7/31/06, the fee schedule amount is $1326.63 as seen in the following equation: [$1128.58 + CPI of 4.1% (+ CPI of 4.0%) (+ CPI of 4.4%) (+ CPI of 3.4%)] = $1326.63.
4. The 2001 Medicare Part B fee schedule amount for a Lumbar MRI (CPT 72148) at issue in this case performed in Region 3 is $609.44. For an accredited facility, 200% of that amount is $1218.88, and PIP would then pay 80% of that amount for an MRI performed prior to August 1, 2002, or $975.10.
For that same MRI performed the following year, between 8/1/02 and 7/31/03, the fee schedule amount is $1268.85 as seen in the following equation: [$1218.88 + CPI of 4.1%] = $1268.85.
For that same MRI performed the following year, between 8/1/03 and 7/31/04, the fee schedule amount is $1319.61 as seen in the following equation: [$1218.88 + CPI of 4.1% (+ CPI of 4.0%)] = $1319.61.
For that same MRI performed the following year, between 8/1/04 and 7/31/05, the fee schedule amount is $1377.67 as seen in the following equation: [$1218.88 + CPI of 4.1% (+ CPI of 4.0%) (+ CPI of 4.4%)] = $1377.67.
For that same MRI performed the following year, between 8/1/05 and 7/31/06, the fee schedule amount is $1432.78 as seen in the following equation: [$1218.88 + CPI of 4.1% (+ CPI of 4.0%) (+ CPI of 4.4%) (+ CPI of 3.4%)] = $1432.78.
5. As a result of the foregoing, the correct amount for the cervical MRI in this case, CPT Code 72141 performed on July 31, 2006 in the Region of Broward County is $1,326.63, 80% of which is $1061.31; and the correct amount for the lumbar MRI in this case, CPT Code 72148 performed on July 31, 2006 in the Region of Broward County is $1,432.78, 80% of which is $1146.22. Therefore, the total payable amount for the cervical and lumbar MRI’s at issue is $2207.53 less payments in the amount of $2133.14 leaves a balance due in the amount of $74.39 + statutory interest in the amount of $6.75 for a total amount due in the amount of $81.04.
ORDERED AND ADJUDGED that Plaintiff’s Motion for Final Summary Judgment is hereby GRANTED. The Plaintiff is awarded Final Summary Judgment in the amount of $81.04 that shall bear interest at the rate of 11% for which let execution issue.
