17 Fla. L. Weekly Supp. 1029a
Online Reference: FLWSUPP 1710CORTInsurance — Personal injury protection — Coverage — Medical expenses — CPT coding — National Correct Coding Initiative is incorporated in Florida PIP law as part of Medicare pay system — Where medical provider improperly unbundles services when billing for comprehensive treatment charge and component treatment charge, neither insurer that paid comprehensive treatment charge nor insured was obligated to pay for unbundled amount — Question certified
ALEXANDRA HEALTHCARE, LLC d/b/a KIRKMAN CHIROPRACTIC a/a/o JUSTIN CORTES, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 09-SC-7747. May 6, 2010. John E. Jordan, Judge. Counsel: Debra Botwin, Debra Wilkinson Botwin, LLC, Orlando. John L. Morrow, Conroy, Simberg, Ganon, Krevans, Abel, Lurvey, Morrow & Schefer, P.A., Orlando.
SUMMARY FINAL JUDGMENT FOR DEFENDANT
THIS CAUSE, having come on before this Court on Defendant’s and Plaintiff’s respective Motions for Summary Judgment, and the Court having reviewed the Motions, Applicable Law, and having heard arguments of counsel, finds that there are no material facts in dispute and that Defendant, State Farm Mutual Automobile Insurance Company (“State Farm”) is entitled to a Final Judgment as a matter of law. It is therefore ordered and adjudged as follows:
1. Defendant’s, State Farm, Motion for Summary Judgment dated December 12, 2009 is granted.
2. Plaintiff’s Motion for Summary Judgment dated October 13, 2009 is denied.
FINDINGS OF FACT AND CONCLUSIONS OF LAW:
The Court has reviewed the motions, attachments thereto, affidavits of record, Fla. Stat. §627.736, Office of Inspector General (OIG) publications and the National Correct Coding Initiative (NCCI) Manual including its edits. The Court concludes Medicare Part B includes the National Correct Coding Initiative and, therefore, is part of the allowable amount under the participating physician’s fee schedule for Medicare Part B.
This Court finds that Plaintiff improperly unbundled its services provided when billing, in violation of Fla. Stat. §627.736(5)(b)(1). Plaintiff’s bills also failed to comply with §627.736(5)(b).
This Court rejects Plaintiff’s argument and accepts Defendant’s argument on the meaning of Section (5)(a)4. The inclusion of this paragraph into the statute excepts out only two sections of the Medicare system that the legislature did not want to include in Florida Personal Injury Protection law. In essence, the legislature adopted the Medicare pay system and excluded out only those two sections that they did not want to apply to Florida law. This means that all other Medicare guidelines, rules and regulations should apply to subsection 5.
Since the Court finds that Plaintiff unbundled services, neither the insured nor the insurer was obligated to pay the Plaintiff provider for the unbundled amounts for the dates of service in the Complaint.
IT IS THEREFORE ORDERED and ADJUDGED, as follows:
Final Judgment be and same is hereby entered in favor of Defendant State Farm Mutual Automobile Insurance Company and against Plaintiff. Plaintiff takes nothing by this action and State Farm shall go hence without day. The Court reserves jurisdiction to award attorney fees and costs.
The court also finds that this issue is of great public importance and hereby certifies the following question to the 5th District Court of Appeal:
WHETHER STATE FARM PROPERLY DENIED PAYMENT OF PLAINTIFF PROVIDER’S UNBUNDLED COMPONENT TREATMENT CHARGE, WHEN IT PAID THE MORE COMPREHENSIVE TREATMENT CHARGE, PURSUANT TO THE NATIONAL CORRECT CODING INITIATIVE COMPREHENSIVE EDITS DATABASE (NCCI EDITS) UNDER FLORIDA’S NO FAULT (PIP) STATUTE.
