14 Fla. L. Weekly Supp. 87a
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 MRIs
DIAGNOSTIC CLINICAL IMAGING, INC., Plaintiff, vs. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 50-2006-SC-001877XXXXSB. October 24, 2006. Debra Moses Stephens, Judge. Counsel: Harley N. Kane, Kane & Kane, Boca Raton. Maury Udell.
ORDER GRANTING PLAINTIFF’S MOTION FOR FINAL SUMMARY JUDGMENT
This cause came before the Court on October 16th, 2006 for hearing on the parties Cross Motions for Summary Judgment, and the Court’s having reviewed the Motions 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 Complaint seeking damages 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 accredited MRI provider is entitled to be reimbursed for CPT Code 72141 and CPT Code 72148, date of service October 19th, 2005 in the Region of Palm Beach County.II. FACTS
The following facts are undisputed: Defendant, PROGRESSIVE EXPRESS INSURANCE COMPANY insured Antoles Jean Baptiste under an 80% policy which provided PIP benefits in accordance with Florida Law. Plaintiff performed two MRIs: CPT Code 72141 and CPT Code 72148, on October 19th, 2005 on the insured, Antoles Jean Baptiste, which was a reasonable, related and necessary service resulting from an automobile accident that occurred on June 18th, 2005. Defendant, PROGRESSIVE EXPRESS INSURANCE COMPANY was given timely notice of the bill for the amount of $3,600.00. Defendant issued payment in the amount of $1781.26 (80% of $2226.57).
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 the allowable amount a medical provider may charge for an MRI. Plaintiff argues that the correct application of the statute in conjunction with the CPI realizes $2418.95 as the allowable amount that a medical provider may charge for the two MRIs 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:
“[A]llowable 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 1st, 2005 and 4.0% for services rendered after August 1st, 2005 but before August 1st, 2006.
3. To illustrate, the 2001 Medicare Part B fee schedule amount for two MRI’s (CPT 72141 and CPT 72148) at issue in this case performed in Region 3 are $564.29 and $609.44 respectively. For a non-accredited facility, 175% of those amounts are $987.51 and $1066.52 and PIP would pay 80% of that amount for MRIs performed prior to August 1, 2002.
For those same MRIs performed the following year, between 8/1/02 and 7/31/03, the fee schedule amounts are $1028.00 and $1110.25 as seen in the following equations: [$987.51 + CPI of 4.1%] = $1028.00 and [$1066.52+CPI of 4.1%] = $1110.25.
For those same MRIs performed the following year, between 8/1/03 and 7/31/04, the fee schedule amounts are $1069.12 and $1154.66 as seen in the following equations: [$987.51 + CPI of 4.1% + CPI of 4.0%] = $1069.12 and [$1066.52 + CPI of 4.1% + CPI of 4.0%]= $1154.66.
For those same MRIs performed the following year, between 8/1/04 and 7/31/05, the fee schedule amounts are $1116.16 and $1205.46 as seen in the following equations: [$987.51 + CPI of 4.1% + CPI of 4.0% + CPI of 4.4%] = $1116.16 and [$1066.52 + CPI of 4.1% + CPI of 4.0% + CPI of 4.4%]= $1205.46.
For those same MRIs performed the following year, between 8/1/05 and 7/31/06, the fee schedule amounts are $1165.27 and $1253.68 as seen in the following equations: [$987.51 + CPI of 4.1% + CPI of 4.0% + CPI of 4.4% + CPI of 4.0%] = $1165.27 and [$1066.52 + CPI of 4.1% + CPI of 4.0% + CPI of 4.4% + CPI of 4.0%] = $1253.68.
4. As a result of the foregoing, the correct amount for the subject MRIs in this case, CPT Code 72141 and CPT Code 72148 performed on October 19th, 2005 in the Region of Palm Beach County are $1,165.27 and $1,253.68 for a total of $2418.95.
5. The Defendant was required to pay 80% of $2418.95 or $1935.16. The defendant only paid $1781.26.
ORDERED AND ADJUDGED that Plaintiff’s Motion for Final Summary Judgment is hereby GRANTED and the Defendant’s Motion for Final Summary Judgment is DENIED. Plaintiff shall recover $156.90 plus prejudgment interest of $12.94 for a final judgment amount of $169.84 for which let execution issue. The Court finds the plaintiff is entitled to attorney fees and costs pursuant to F.S. 627.736 and F.S. 627.428. The Court reserves jurisdiction to determine the amount of fees and costs should the parties not agree.
