15 Fla. L. Weekly Supp. 1004b
Insurance — Personal injury protection — Coverage — Medical expenses — Bill in excess of customary charges — Where medical provider charged PIP insurer amount for x-ray interpretative services in excess of what it charges other entities with which it has agreements to provide same services, provider violated statutory requirement that charges to PIP insurer not exceed amount provider customarily charges for like services — Provider is not entitled to recover disputed balance of reduced bill
CHIROPRACTIC RADIOLOGY CONSULTANTS, P.A., (a/a/o GREGORY MILLER), Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami Dade County, Civil Division. Case No. 06-12558 SP 05 (06). August 1, 2008. Catherine M. Pooler, Judge. Counsel: Michael Libman, for Plaintiff. Reuven T. Herssein, Law Offices of Herssein & Herssein PA, North Miami, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on hearing on July 18, 2008 on Defendant’s Motion for Final Summary Judgment. The Court, having reviewed the motion, the Court file, legal authorities and having heard argument of counsel, finds as follows:
Factual Background:
This is a Personal Injury Protection (“P.I.P.”) case where Chiropractic Radiology Consultants, P.A. (“CRC”) submitted charges to Progressive American Insurance Company (“Progressive”) for the interpretation of x-ray films taken of the assignor, Gregory Miller.
Progressive received a bill from CRC totaling $450.00, for the interpretation of three (3) x-rays rendered to Gregory Miller on March 13, 2006. CRC charged Progressive $150.00 for each interpretation. Specifically, CRC charged Progressive $150.00 for CPT Code 72040-26; $150.00 for CPT Code 72070-26 and $150.00 for CPT Code 72100-26. Upon receipt of the bill from CRC, Progressive allowed and paid $23.94 for each CPT Code billed by the Plaintiff, for a total of $71.82. This PIP law-suit arose out of Progressives’ reduction of CRC’s bill.
During the deposition of CRC’s representative, Deborah Brahee, Progressive learned that CRC has agreements with different entities to provide x-ray interpretation services for $10-$15 per interpretation. The interpretation services are the exact same x-ray interpretation services billed to Progressive at the $150.00 rate. Deborah Brahee further testified that CRC had agreements with at least six (6) facilities, wherein CRC charged this reduced rate for x-ray interpretation services. CRC had this agreement with Physician’s First Choice Interpretations, Inc., (hereinafter “PFC”). When questioned on the agreement between CRC and PFC, Deborah Brahee testified that if CRC had been interpreting x-rays of Gregory Miller for PFC, they would have charged PFC a total of $30.00, not the $450.00 charged to Progressive in this case. In the instant case, CRC submitted charges to Progressive which were fifteen (15) times the amount CRC charges other entities for the same exact medical services — x-ray film interpretations.
Legal Conclusions:
When a provider bills an insurer for medical services, Florida Statute section 627.736(5)(a) (2006) states in pertinent part,
Any physician, hospital, clinic or institution lawfully rendering treatment to an injured person . . . covered by personal injury protection insurance may charge the insurer and injured party only a reasonable amount. . . . . .In no event, however, may such a charge be in excess of the amount the person or institution customarily charges for like services or supplies.
The PIP statute expressly states that providers may not charge a PIP insurer more than what they customarily charge for “like services” that are not billed to PIP insurers. It is significant to note that the legislature specifically uses the term “like services” not “same services.” The statute does not limit its proscription to services that are exactly the same or are billed under the same code. Regardless, in this instance, it is undisputed that CRC charged Progressive $450.00 for the exact same service it would have charged PFC, $30.00 for. In fact, the evidence before this Court is that CRC would have charged PFC $30.00 for the same CPT codes — 72040-26; 72070-26 and 72100-26 billed to Progressive. The practice of charging an amount in excess of what it would charge another entity for “like services” is a violation of Florida Statutes §627.736(5)(a) (2006).
Recently, the 13th Judicial Circuit Court, sitting in its Appellate Capacity ruled that charging different amounts for “like services” is a violation of Florida Statutes §627.736(5)(a) (2006). Progressive Consumers Insurance Company vs. Craig A. Newman, 15 Fla. L. Weekly Supp. 129a (Fla. 13th Jud. Cir. July 17, 2007). In the Newman case, the provider was charging the PIP insurer (for x-rays) substantially more than they charged patients under a cash-payment plan they had set up. Under the cash payment plan, the provider in Newman would charge $160.00 for the same services it billed the PIP insurer $650.00. The Court in Newman found this to be a violation of the Statute and rejected the provider’s argument that if the provider did not make a habit of accepting less money, then it did not fall under the auspices of the Statute. The Newman Court ruled that the provider was not entitled to recover the balance owed from the PIP insurer, as the provider may not charge the insurer more than he does for an uninsured patient. The Newman Court ruled that the provider violated Florida Statutes §627.736(5)(a) and was not entitled to recover the disputed balance. The facts in the case before this Court are strikingly similar to that of the Newman facts. In this case, CRC has agreements with other entities, where CRC charges $10.00 for the exact same service it charged Progressive $150.00 for. In so doing, CRC violated §627.736(5)(a) (2006), and is not entitled to recover the remaining balance of its bill.
Similarly, in Kenneth Hawthorne, M.D. v. Progressive Express Insurance Company, 12 Fla. L. Weekly Supp. 265a (Fla. 7th Jud. Cir. December 15, 2004), the Court found that giving cash patients a fifty percent discount violates Florida Statutes §627.736(5)(a). The Hawthorne Court noted that while a small reduction for cash patients may be understandable, a fifty percent discount was startling. The Court ruled that the provider was illegally charging the insurance companies a premium rate. The Hawthorne opinion applies to the present case, because as in the Hawthorne case, here CRC established agreements wherein it gave facilities approximately a ninety-three percent (93%) discount on x-ray interpretation services. A provider that charges the insurer substantially more than it customarily charges for “like services” violates Florida Statutes §627.736(5)(a) (2006) and is not entitled to recover any disputed balance from the insurer.
Accordingly, it is hereby:
ORDERED AND ADJUDGED that PROGRESSIVE AMERICAN INSURANCE COMPANY’S Motion for Final Summary Judgment is GRANTED. The Plaintiff, CHIROPRACTIC RADIOLOGY CONSULTANTS, P.A., (a/a/o GREGORY MILLER) shall take nothing in this action, and Plaintiff shall go hence without day.
This Court reserves jurisdiction to determine reasonable attorney fees and costs.
