17 Fla. L. Weekly Supp. 1227b
Online Reference: FLWSUPP 1712TEP
Insurance — Personal injury protection — Coverage — Medical expenses — MRI — Where Medicare Part B participating physicians fee schedule is only fee schedule specifically identified in PIP statute, that schedule and not Medicare’s Hospital Outpatient Prospective Payment System fee schedule should be used by insurers when calculating payment for MRI services under PIP statute
CENTRAL IMAGING OPEN MRI, INC., As assignee of Bradley Tep, Plaintiff, vs. MERCURY INSURANCE COMPANY OF FLORIDA, Defendant. County Court, 6th Judicial Circuit in and for Pinellas County, Small Claims Division. Case No. UCN 522008SC011151XXSCSC. REF. No. 08011151 SC046. July 23, 2010. Edwin B. Jagger, Judge. Counsel: Marc B. Nussbaum, Reeder & Nussbaum, P.A., St. Petersburg, for Plaintiff. Scott Dutton, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AND DENYING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT
THIS CAUSE having come before the Court on March 11, 2010, on the Parties’ competing Motions for Summary Judgment, and the Court having considered the motions and argument presented by counsel, and being otherwise duly advised in the premises, rules as follows:
The insured was involved in a motor vehicle accident, sustained bodily injuries, and received MRI services from the Plaintiff. The Plaintiff billed under the insured’s PIP insurance policy and was reimbursed a sum certain. The Plaintiff claims that the Defendant incorrectly reduced the required allowable amount by applying a fee schedule (“OPPS”) not authorized under Florida’s No-Fault PIP statute.
The issue presented here is the proper interpretation of language contained in Fla. Stat. §627.736(5)(a)2f, which provides that an insurer may limit reimbursement to 80 percent of “200 percent of the allowable amount under the participating physicians schedule of Medicare Part B.” Section 627.736(5)(a)3 further adds that the reimbursement amount shall not be less than “the allowable amount under the participating physicians schedule of Medicare Part B for 2007.”
The Plaintiff contends that reimbursement under the PIP statute should be made only by reference to the “participating physicians schedule” of Medicare Part B. The Defendant asserts that it correctly calculated payment based upon the “actual” amount allowable by the federal government for MRI services under applicable Medicare rules.
The PIP statute does not define the phrases “allowable amount” and/or “participating physicians schedule.” Various lower court judges in Florida have addressed the issue and there is a difference of opinion on the proper interpretation. To date, there is no appellate authority.
From a plain reading of the statutory language, this Court concludes that the interpretation offered by the Plaintiff is the one most sensible. The referenced “participating physicians schedule” of Medicare Part B is the only fee schedule specifically identified in the statute; and, as such, the one that should be used by insurers when calculating payment for MRI services under the PIP statute. The express language suggests that the Florida Legislature intended to exclude any other payment system or schedule under the Medicare statute.
Accordingly, it is hereby ORDERED AND ADJUDGED that the Plaintiff’s Motion for Summary Judgment is GRANTED and the Defendant’s Motion for Summary Judgment is DENIED. The Court will reserve jurisdiction on any issue related to attorney’s and costs.
