14 Fla. L. Weekly Supp. 176b
Insurance — Personal injury protection — Discovery — Interrogatories — Computer database used to review bills — Insurer relying on computer database as defense in asserting that bills are unreasonable is ordered to provide information regarding underlying formula, criteria and methodology utilized to determine amount allowed, scale or schedule of reasonable billing amounts used to reduce bills, and list of medical providers in county currently billing at rates insurer elected to pay for period three months before and three months after first date of service at issue — Insurer also required to provide name and address of any providers in county to which insurer paid higher amount during same period, with explanation for higher payment — Defense can be waived by failure to provide this information
NADAL MEDICAL CENTER, INC., (as assignee of Marie Joseph), Plaintiff, v. DAIRYLAND INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Small Claims Division. Case No. 06 6512, Division L. December 21, 2006. John N. Conrad, Judge. Counsel: Timothy A. Patrick, Nicholas, Lipscomb & Patrick, P.A., Tampa, for Plaintiff. David A. Boulos, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION TO COMPEL
This cause having come before the Court on December 13, 2006, on Plaintiff’s Motion to Compel Better Answers to Plaintiff’s Second Interrogatories, with Timothy A. Patrick, Esquire appearing on behalf of Plaintiff and David Boulos, Esquire appearing on behalf of Defendant, and the Court, being fully advised in the premises, rules that for the reasons stated on the record and recorded in open court, which constitutes the decision of this Court,
It is ORDERED and ADJUDGED:
Plaintiff’s Motion to Compel is HEREBY GRANTED to the extent listed below. The court finds that the Plaintiff is entitled to any information that Mitchell Medical Systems and/or Ingenix relied upon in forming its opinions and the basis therein. To the extent that the Defendant is relying upon the Mitchell Medical/Ingenix database as a defense in asserting that the subject medical bills are unreasonable, said defense can be waived by the failure to provide this information.
1. With respect to the Explanation of Medical Bill Payments attached as “Exhibit A,” please describe in detail the exact methodology used to determine that the “amount allowed is based on provider charges within the provider’s geographic region.”
Plaintiff’s motion is GRANTED. The court finds that the only way to assess the correctness of the Mitchell/Ingenix recommendations is to know the underlying formula, criteria and methodology utilized.
2. With respect to the Explanation of Medical Bill Payments attached as “Exhibit A,” please specify the exact formula or criteria used to determine the “amount allowed” for CPT Code 72040; CPT Code 73030; and CPT Code 73560.
Plaintiff’s motion is GRANTED.
3. With respect to the Explanation of Medical Bill Payments attached as “Exhibit “A,” if the formula or criteria used to determine the “amount allowed” for CPT Code 72040; CPT Code 73030; and CPT Code 73560, was determined by software or services provided to Defendant by a third party vendor or other outside source, please give the full name, address, and phone number of that entity and the full name of your primary contact person at that entity.
Plaintiff’s Motion is DENIED as Defendant provided this information.
4. If you have failed to tender the full payment for the medical bill submitted for treatment rendered by the Plaintiff to the insured, please state the scale or schedule of reasonable billing amounts utilized by you in making this decision, and further indicate a complete list of all medical providers in Hillsborough County, Florida, who are currently billing at the rate(s) you have elected to pay.
Plaintiff’s motion is GRANTED. Defendant must provide this information for the period of three (3) months prior to the first date of service at issue through three (3) months subsequent to the first date of service at issue
5. If you have tendered a reduced payment for the medical bills that were submitted for treatment rendered by the Plaintiff, please state whether, in the past three (3) years, you have ever paid any other medical provider in the same geographical region as the Plaintiff (i.e., Hillsborough County, Florida) a higher amount than that paid for the same treatment or procedure as referenced in the CPT codes on the Plaintiff’s medical bills and, if so, for each such instance state: the name and business address of the other medical provider(s) performed, then amount(s) paid by you, and your explanation why a higher amount was paid to the other providers.
Plaintiff’s motion is GRANTED. Defendant must provide this information for the period of three (3) months prior to the first date of service at issue through three (3) months subsequent to the first date of service at issue
6. With respect to the medical bills submitted by the Plaintiff for payment, please describe the exact methodology used by the Defendant to determine that the “amount allowed is based upon provider charges within the provider’s geographic region.”
Plaintiff’s motion is GRANTED.
7. With respect to the medical bills submitted by the Plaintiff for payment, please specify the exact formula or criteria used to determine the “amount allowed” as indicated on the Defendant’s Explanation of Reimbursement.
Plaintiff’s motion is GRANTED.
Defendant has thirty (30) days from the date of the entry of this Order to provide better answers to Plaintiff’s Second Interrogatories numbered 1, 2, 4, 5, 6, and 7.
