15 Fla. L. Weekly Supp. 1225a
Insurance — Personal injury protection — Notice of loss — Claim form — Professional license number — Where there is no professional license required for MRI facility to perform or bill for MRI, insurer cannot refuse to pay timely presented claim for medically necessary MRI on ground that provider failed to list professional license number in box 31 of CMS-1500 claim form
OAKLAND PARK MRI, INC., Christine Girrbach, Plaintiff, vs. USAA Casualty Insurance Company, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 17-06767-COCE-54. June 11, 2008. Lisa Trachman, Judge. Counsel: Charles J. Kane, Kane & Kane, Boca Raton. Miriam Merlo, Coral Gables.Final Summary Judgment for Plaintiff
On May 16, 2008 the Court heard the Plaintiff’s and Defendant’s respective Motions for Summary Judgment.
Undisputed Facts
Plaintiff provided diagnostic imaging services on June 13, 2006 to Defendant’s covered insured, Christine Girrbach, related to medically necessary treatment for injuries she sustained in a motor vehicle accident on May 3, 2006. It used Ronald I. Landau, M.D., an independent contractor radiologist, for the professional component of the testing. It submitted a timely claim on the right form charging $1374.39 for a cervical billed globally1 under CPT code 72141. The Plaintiff has no professional license and is not regulated by the Florida Department of Professions. But it does have the right to bill for both components of this testing as a matter of law. Regional MRI of Orlando, Inc. v. Nationwide Mutual Fire Ins. Co., 884 So.2d 1102, 1108 (Fla. 5th DCA 2004); F.S. §627.732(14). No deductible applies to this claim.
The claim was mailed June 21, 2006, was timely received, was not paid and was denied.
Box 31 of the claim form requires a signature of the “Physician or Supplier”. It is undisputed Plaintiff is the “Supplier” of the technical component of these services. The claim form was signed by Plaintiff’s authorized representative who is not a professional, has no professional license or credentials and was not involved in making the images or interpreting them. Plaintiff’s medical director is a licensed professional who did not sign the claim form.
Block 31 of the claim form displayed a number, “HCCR 2823”, the last registration number issued to the Plaintiff by the State of Florida prior to the repeal in 2004 of the law requiring registration.2 At all times material Plaintiff had a duly issued healthcare facility license not mentioned in Block 31 of the claim form.
The claim submission included the CMS-1500 form that in all other respects Defendant concedes was properly completed. Accompanying it, among other things, was the written interpretation of Ronald I. Landau, M.D. At all times material the Florida Department of Health maintained a wcbsite pursuant to F.S. §456.041 et seq. showing Dr. Landau’s professional license number accessible by the Defendant whose adjuster had a computer and internet access.The Questions Presented
Plaintiff asserts the following is the question presented:
May an insurer refuse to pay a claim for a medically necessary covered MRI timely presented simply because it fails to list a “professional license number in box 31” of the CMS-1500 billing form where there is no professional license number issued to the MRI supplier?
Defendant asserts the issues are:
(1) Whether the Defendant is on notice of a claim form submitted by an MRI facility billing globally that does not display a professional license in Block 31 of the form; alternatively
(2) Whether the form was inaccurate with respect to a material provision thereby precluding notice to the Defendant?
Analysis
Although Plaintiff is the “Supplier” of these services and has no professional license, Defendant insists it is not on notice of the claim without the professional license number of Dr. Landau displayed in Box 31 even though he did not sign. Defendant relies on its reading of the following from F.S.§627.736(5)(d):
All providers other than hospitals shall include on the applicable claim form the professional license number of the provider in the line or space provided for “Signature of Physician or Supplier, Including Degrees or Credentials.”
Plaintiff is the provider of both components. Regional MRI of Orlando, Inc. v. Nationwide Mutual Fire Ins. Co., 884 So.2d 1102, 1108 (Fla. 5th DCA 2004).
No literal interpretation should be given that leads to an unreasonable or ridiculous conclusion or to a purpose not designated by the lawmakers. . .A law should be construed together with any other law relating to the same purpose such that they are in harmony. Wakulla County v. Davis, 395 So.2d 540 (Fla.1981); Garner v. Ward, 251 So.2d 252 (Fla.1971).
Authority to license and regulate professionals rests with the Department of Business and Professional Regulation. F.S.§ 20.165. The professions governed (and the statutes associated with them) are contained in Title XXXII of Florida Statutes comprising chapters 454 through 493, Florida Statutes. The law regulates professions and other occupations ranging from attorneys at law (Chapter 454) to private investigative, private security, and repossession services (Chapter 493). Some of these chapters relate to health care professions. There is no language in any of these chapters requiring Plaintiff, an independent corporate diagnostic testing company, to be professionally licensed. In fact, just the opposite is true. Chapter 456 regulates health professions and occupations, and applies only to individuals regulated by the Department of Professions. Fla. Stat. § 456.002. Plaintiff and its technicians are not professionals, and Plaintiff is not regulated by the Department of Professions.
Defendant asserts Plaintiff has a professional license because (1) its medical director has one or (2) it used the services of Dr. Landau, the radiologist, who has one. The assertion misses the point — courts must apply the law as written, not as the Defendant wishes it was written. State v. Barquet, 262 So.2d 431 (Fla. 1972). When interpreting statutes, courts “are not at liberty to add words to the statute that were not placed there by the legislature.” State v. J.M. 824 So.2d 105, 111 (Fla.2002) (quoting Hayes v. State, 750 So.2d 1, 4 (Fla.1999)). The provision Defendant relies on does not say “and if the provider is a corporation, then put the professional license of an independent contractor who rendered part of the services”. Neither does the language used require anything displayed involving the medical director who did not sign the claim form. The medical director’s statutory duties are set forth at F.S. §400.9935(1). Those duties do not include rendering either component of this testing.
Clearly, Plaintiff is the provider that submitted the claim. The term “All providers” in the sentence relied on by Defendant clearly refers to Plaintiff as the provider making the claim. The second reference to “provider” in that sentence clearly refers to the first reference, not some other provider of service. Since the Plaintiff has no professional license of its own, it had none to display in Block 31. This court agrees with the analysis in Virtual Imaging Services, Inc. v. USAA Casualty Ins. Co., 14 Fla. L. Weekly Supp. 85a (Miami-Dade County 2006), addressing the non-existent professional license in the context of an MRI provider, holding F. S. §627.736(5)(d) does not apply to MRI facilities as they cannot comply with providing a professional license number for a license they do not have and are not required to have.
Defendant’s position requires providers like Plaintiff to create a false CMS-1500 form. Box 31 of the CMS-1500 form states the following:
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse apply to this bill and are made a part thereof.)
On the back of the CMS-1500 form, the following statements (which are made a part thereof) appear:
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.
SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction.
[Emphasis supplied]
Plaintiff cannot lawfully comply with any provision requiring it to display its professional license number or a professional license number of any of its employees that do not exist. Plaintiff and its technicians merely filled a physician’s script for testing making no determinations of medical necessity. The referring physician is not the “physician or supplier” of the testing, as Plaintiff is the entity that performed the testing. Using that physician’s license number or the radiologist’s license number would violate the two notices contained on the back of the CMS-1500 form and subject Plaintiff (and possibly the physicians) to claims of insurance fraud. Certainly, the public policy of this state cannot promote the reading of a statute to require insurance fraud! Statutes cannot be construed in a manner which would create a ridiculous result. Mackey v. Household Bank, F.S.B., 677 So.2d 1295 (Fla. 4th DCA 1996); Holly v. Auld, 450 So.2d 217 (Fla. 1984); City of Boca Raton v. Gidman, 440 So.2d 1277 (Fla. 1983).
The purpose of the no-fault statute is to encourage “swift and prompt payment of claims for medically necessary” medical treatment without regard to fault — Defendant’s position produces the opposite — Defendant claims its perceived technicality, relieves it of liability For medically necessary diagnostic testing.
Yet it is clear that the claim form was “substantially complete and substantially accurate responses as to all material elements” within the meaning of the term “properly completed”. Fla.Stat. §627.732(13) provides:
(13) “Properly completed” means providing truthful, substantially complete, and substantially accurate responses as to all material elements to each applicable request for information or statement by a means that may lawfully be provided and that complies with this section, or as agreed by the parties.
[Emphasis supplied]
The admissions by Jeannie Hopwood together with the Defendant’s Explanation of Review show there was no confusion over registration versus health care clinic that was not required for the form, and not sought anyway by the Defendant. The form was properly completed.
The Florida No-Fault Insurance Law, F.S.§627.736, was initially enacted in 1971 on the premise that in exchange for giving up their constitutional rights to pursue pain and suffering damages for nonpermanent injuries sustained in motor vehicle accidents, the injured persons would be entitled to swift and prompt payment of claims for medically necessary and reasonable expenses incurred and for lost wage benefits. Ivey v. Allstate Ins. Co., 774 So.2d 679 (Fla.2000). That purpose has not changed. Warren v. State Farm Mutual Automobile Insurance Company, 899 So.2d 1090 (Fla. 2005). There is no doubt this service is payable. Defendant admits the injuries this patient sustained were related to the covered motor vehicle accident and that the testing was related and medically necessary. Defendant’s assertion is simply that a professional license number must be in box 31. No agency in Florida issues a professional license to independent corporate diagnostic testing companies like the Plaintiff.
“Laws should be enforced with common sense and applied without losing sight of the legislative purpose behind their enactment. To do otherwise is to generate disrespect for the law by creating a morass of technical regulations with no connection to human experience.” Mackey v. Household Bank, F.S.B., 677 So.2d 1295 (Fla. 4th DCA 1996). The law expressly excludes hospitals from this requirement. Hospitals are licensed pursuant to law adopted at Ch. 395, Fla. Statutes. They are not regulated by the Department of Professions and have no professional licenses. That exclusion shows legislative intent to exempt non-professionals from this requirement.
Allowing an insurer to avoid contractual obligations where the law cannot be applied to Plaintiff runs contrary to the purpose of no-fault law. One such case illustrating this point is Evans Packing Company v. Department of Agriculture and Consumer Services, 550 So.2d 112 (Fla. 1st DCA 1989), where the Court overturned an administrative conviction of an orange juice packing plant. The Court held:
if the act requires an impossible thing to be done, or something to be done in an impossible manner, the courts may declare it incapable of enforcement in a particular case, but that such fact does not invalidate the statute; “All statutes must receive a sensible construction, such as will effectuate the legislative intention, and, if possible, so as to avoid an unjust or an absurd conclusion.
Defendant’s assertion inclusion of “HCCR 2823” in Block 31 precludes notice is without merit. Defendant’s Explanation of Reimbursement did not address it. Defendant’s adjuster, JEANNIE HOPWOOD, admitted the HCCR number presented no cause for concern (Deposition of Jeannie Hopwood at p. 25):
Q Did any of the explanations of reimbursement object to or request any more information about the HCCR number?
A No, because the HCCR number is not required.
Defendant’s assertion a validly issued registration number is inaccurate merely because it expired under a repealed law misinterprets Plaintiff’s representation of something that was not material anyway.3 Only after this litigation commenced did the Defendant express some concern over that number that it confused with a health care clinic license number that is prefaced by only 3 letters, “HCC”, and that its representative admits was no cause for concern. The admissions by Jeannie Hopwood show the claim form was properly completed subject to her reservation of the legal argument that Dr. Landau’s license number needed to be on the form. Defendant’s current position is merely an attempt to avoid liability for failure to pay by raising an issue elevating form over substance that is generally disapproved. Salcedo v. Asociacion Cubana, Inc., 368 So.2d 1337, 1339 (Fla. 3rd DCA 1979).
Defendant’s motion is denied.
Plaintiff is awarded summary final judgment in the principal amount of $1099.51 (80% of $1374.39) together with prejudgment interest from June 26, 2006 ($5016/100at 9% per annum for the balance of 2006, plus $120.95 at 11% for 2007, plus 11% per annum from 1/1/08 to date) for which let execution issue, plus reasonable attorneys fees and costs for which jurisdiction is reserved.
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1A global bill charges for both the technical work in making the images as well as the professional work in interpreting what the images mean.
2Fla. Stat. §456.0375 addressing registration of certain health care facilities was repealed effective March 1, 2004. Laws 2003, Ch. 2003-411 §15
3Health care clinic licenses are issued pursuant to Part II of Ch. 408 and are required by F.S.§ 400.991(1)(a), both provisions falling under Title XXIX, Florida Statutes. Professions are regulated under Title XXXII, Florida Statutes. The two classes of licensure are mutually exclusive.
