17 Fla. L. Weekly Supp. 718a
Online Reference: FLWSUPP 1708FUME
Insurance — Personal injury protection — Claim form — Name and professional license number — Omission of medical provider’s name and professional license number from claim form constitutes failure to provide notice of covered loss
HEALTH ALLIANCE INJURY & PAIN MANAGEMENT, (a/a/o Fumero, Magaly & Fumero, Oscar), Plaintiff, v. U.S. SECURITY INSURANCE COMPANY, Defendant. County Court in and for Miami-Dade County. Case No. 07-05399 CC 05. Florida Bar No. 626880. May 24, 2010. Wendell M. Graham, Judge. Counsel: Wajih Shirazi, Law Office of Neil M. Gonzalez, Miami, for Plaintiff. Wendy Cook, Hamilton House Counsel, Miami, for Defendant.
ORDER ON DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court for hearing on April 5, 2010 upon Defendant’s Motion for Final Summary Judgment, and having been otherwise duly advised in the premises, the Court finds:
UNDISPUTED MATERIAL FACTS
1. Defendant, U.S. Security Insurance Company issued an automobile insurance policy applicable to Magaly and Oscar Fumero, which included Personal Injury Protection (PIP) benefits in accordance with Florida Statute § 627.736.1
2. Mr. and Ms. Fumero claimed injuries as a result of an automobile accident that reportedly occurred on June 27, 2005.
3. Pursuant to an Assignment of Benefits, Plaintiff billed Defendant for reimbursement under the PIP portion of Mr. and Mrs. Fumero’s policy.
4. Plaintiff submitted bills to Defendant on CMS 1500 forms also known as “HCFA” forms (bills) for the dates of service at issue in this suit of July 7, 2005 through and including October 19, 2005.
5. All of the HCFAs submitted by Plaintiff, as well as the attached notes, were completely devoid of any information that would allow the insurer the ability to identify anyone who personally furnished the treatment or supervised the treatment. Box 31 on the HCFAs stated the name of the clinic (Health Alliance Pain Management) with an illegible signature. There was no indication of who personally furnished the treatment or who supervised the treatment in Box 31. The Tax I.D. Number (T.I.N.) on the HCFAs also did not provide any such information as the T.I.N. was registered to the Plaintiff.
6. Defendant repeatedly advised Plaintiff that the bills were not considered notice of a covered loss or notice of the claim in accordance with Florida Statute §627.736(5)(d). However, Plaintiff failed to provide the name or license number of the licensed professional who personally furnished the treatment or supervised the treatment.2
7. Plaintiff filed this lawsuit to recover payment for said bills.
8. Defendant filed for final summary judgment on the grounds that Plaintiff’s bills were non-compensable under Florida Law.
LEGAL ANALYSIS
9. Florida Statute § 627.736(5)(d) states in part that “[a]ll statements and bills for medical services rendered by any physician, hospital, clinic, or other person or institution shall be submitted to the insurer on a properly completed Centers for Medicare and Medicaid Services (CMS) 1500 form. . .” This section further states that “. . .[a]ll billings for such services rendered by providers shall, to the extent applicable comply with the Centers for Medicare and Medicaid Services (CMS) 1500 form instructions.”3
10. In 2003, the Legislature expressly added within §627.736(5)(d) Fla. Stat. language stating that “[a]ll 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.”
11. This section also provides the consequence for failing to adhere to this provision by stating: “[f]or purposes of paragraph (4)(b), an insurer shall not be considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph, and unless the statements or bills are properly completed in their entirety as to all material provisions, with all relevant information being provided therein §627.736(5)(d) Fla Stat. (Emphasis added).4
12. As a result, the inclusion of the professional license is not optional and the insurance company is statutorily barred from paying these bills if the clinic fails to adhere to the proper billing requirements under the PIP Statute.
13. The ruling of this Court is distinguishable from this jurisdiction’s appellate decision in United Automobile Insurance Company v. John Ortiz, D.C., a/ a/ o Paula Almorose, 16 Fla. L. Weekly Supp. 620a (Fla. 11th Jud. Cir. App. April 30, 2009). In that case, the HCFA forms were deemed properly completed as to all other provisions except for the license number in the signature block. The Court held that the forms contained the name of the physician providing the services. Therefore, the license number was easily obtainable by visiting the Florida Department of Health website. Thus the inclusion of the license number on the HCFA forms in that case was not deemed a “material” omission.
14. In the instant case, however, U.S. Security had no indication on the HCFA, or the notes attached thereto, of the name of the licensed medical provider who performed or supervised any of the alleged treatment.
15. This case is also distinguishable from the recent decision from the Third District in the case of United Automobile v. Professional Medical Group (Gaston Botta), 26 So.3d 21 (3 DCA Fla. 2009). In the Botta case the insurer deemed the bills non-compliant as the plaintiff failed to provide the physician’s license number in Box 31. However, the Court determined that the bills were “substantially complete” as the name of the physician was listed in Box 31 in the initial set of bills. The Court also focused on the fact that the insurer did not object to the missing physician license number. Furthermore, the Court determined that the error was corrected as the plaintiff provided the missing information when it resubmitted the bills with the missing information.
17. In the instant case the HCFAs and the attached notes were completely devoid of any information that would allow the insurer the ability to identify anyone who personally furnished the treatment or supervised the treatment. The Defendant repeatedly put the Plaintiff on notice that the bills were non-compliant yet no attempt to cure was ever made. Plaintiff never resubmitted the bills with the missing information.
18. Therefore, the bills at issue are not payable under Florida Statute 627.736(5)(d) as the insurer was not provided with notice of a covered loss.
RULING
THIS CAUSE having come before the Court and the Court being otherwise fully advised in the premises, it is hereby:
ORDERED and ADJUDGED that:
1. Defendant’s Motion for Final Summary Judgment is GRANTED.
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1The policy included a deductible of $1,000.00 applicable to each claimant.
2U.S. Security sent letters to the Plaintiff nine days after receipt of the first batch of bills and multiple times thereafter.
3On the reverse side of the HCFA in reference to Box 31 it states the following: “I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished into my professional service by my employee under my immediate personal supervision except as otherwise expressly permitted by Medicare.”
4The Third District Court of Appeals case of Pedro Ortega v. United Automobile Insurance Company, 847 So.2d 994, Fla. App. 3 Dist. (2003) is not applicable to the instant case. In Ortega the Court held that Florida Statutes §627.736(5)(d) did not require substantiation of the medical provider’s licensure, it only stated that medical services cannot contain charges for services performed by unlicensed individuals or entities. This case was based on the 1998 version of Florida Statutes. At that tine the relevant portion of the statute simply stated, “No statement of medical services may include charges for medical services of a person or entity that performed such services without possessing the valid licenses required to perform such services.
