17 Fla. L. Weekly Supp. 1121b
Online Reference: FLWSUPP 1711HARV
Insurance — Personal injury protection — Coverage — Medical expenses — Exhaustion of policy limits — Where insurer did not act in bad faith in down-coding CPT codes and applying negotiated PPO adjustment, and payment sent after receipt of demand letter seeking balance of reduced claims exhausted benefits, there can be nothing further due and owing from insurer — No merit to argument that medical provider’s failure to deposit check sent in response to demand letter means benefits have not been exhausted
ORTHOPAEDIC CENTER OF SOUTH FLORIDA, P.A., (A/A/O EDWARD M. HARVEY), Plaintiff, vs. USAA CASUALTY INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 09-14848 COCE 54. June 17, 2010. Lisa Trachman, Judge. Counsel: Matt Hellman, P.A., for Plaintiff. Reuven T. Herssein, Herssein and Herssein, P.A., North Miami, for Defendant.
ORDER GRANTING USAA CASUALTY INSURANCE COMPANY’S MOTION FOR FINAL SUMMARY JUDGEMENT
THIS CAUSE coming for hearing on June 2, 2010 on USAA CASUALTY INSURANCE COMPANY’S (“USAA”) Motion for Summary Judgment, and the Court having reviewed the motion, heard argument of counsel and being otherwise fully advised in the premises, the Court finds as follows:
UNDISPUTED FACTS
1. Edward Harvey, the claimant, sustained personal injuries in an auto accident on November 6, 2008, for which Orthopedic Center of South Florida (“Plaintiff”) treated him from November 24, 2008 until August 10, 2009. The Plaintiff then submitted bills for the treatment to USAA, Edward Harvey’s insurer. USAA issued a policy of insurance, which was in effect from June 16, 2008 to December 16, 2008 to Chu Un Harvey, and provided ten thousand dollars ($10,000.00) in Personal Injury Protection Benefits (“PIP”) for Edward Harvey. The subject policy of insurance did not provide for Medical Payments (“MedPay”) or other extended PIP coverage.
2. This case involves only two dates of service; April 14, 2009 and June 16, 2009, for the same office visit, codified as CPT code 99214. The Plaintiff billed $195.00 for CPT code 99214 on each of the above mentioned dates of service.
3. After contacting the Plaintiff, USAA down-coded both CPT codes from a 99214 to CPT code 99213, and then reimbursed the Plaintiff $90.94 for each date of service. The reimbursement amount is based on 200% of the applicable Medicare Part B Fee Schedule for CPT code 99213, at 80%, reduced by 10%, in accordance with the Three Rivers Providers Network (TRPN) PPO agreement the Plaintiff signed.
4. USAA’s file and the file of the Plaintiff both indicate that the Plaintiff was contacted to discuss the Plaintiff’s reason for billing CPT Code 99214, and was informed that USAA was going to down-code CPT Code 99214 to 99213, as CPT Code 99214 was not supported by the documents submitted.
5. On September 14, 2009, counsel for the Plaintiff sent USAA a pre-suit demand letter for the two dates of service at issue, April 14, 2009 and June 16, 2009. In response to the pre-suit demand letter, on October 21, 2009, USAA issued a $25.75 draft — exhausting all remaining PIP benefits under the policy of insurance and informed counsel for the Plaintiff that $25.75 draft exhausted all benefits available under the policy of insurance at issue.
FINDINGS OF LAW
It is well settled law that an insurance company is not required to pay more than the amount it contractually agreed to pay. See, Simon v. Progressive Express Ins. Co., 904 So 2d 449 (Fla. 4th DCA 2005); see also B&D Chiropractic Center (a/a/o Lina Yepes) v. Progressive Express Ins. Co. 15 Fla. Law Weekly Supp. 334a (17th Jud. Cir. Appellate Nov. 6, 2007); Millennium Diagnostic Imaging Center, Inc. a/a/o Alfonso Taboada v. Progressive Express Ins. Co., 987 So 2d 755 (Fla. 3d DCA 2008); and Progressive American Ins. Co. v. Stand-Up MRI of Orlando (a/a/o Isaac Eusebio), 990 So 2d 3 (Fla. 5th DCA 2008).
In this instance, the record evidence is undisputed that the policy of insurance at issue contained only ten thousand dollars ($10,000.00) in PIP benefits and did not provide for Medical Payments or other extended PIP coverage. Accordingly, because USAA has paid the amount it contractually agreed to pay, ten thousand dollars ($10,000.00), there can be no additional amounts due and owing.
This Court finds the Plaintiff’s argument that benefits have not actually exhausted, because the $25.75 draft USAA sent in response to the pre-suit demand letter was not deposited, is wholly without merit. The Plaintiff essentially argues that the check must be cashed in order for the payment to become effective, an argument that is not supported by the clear language of Florida Statute §627.736. Moreover, the argument is akin to arguing that an insurer may float checks — a practice not permissible under Florida Law.
The fact that the Plaintiff never deposited the $25.75 draft issued by USAA in response to the pre-suit demand letter, does not mean that there are policy benefits remaining. Florida Statute §627.736(10)(d) states, “For purposes of this subsection, payment or the insurer’s agreement shall be treated as being made on the date a draft or other valid instrument that is equivalent to payment, or the insurer’s written statement of agreement, is placed in the United States mail in a properly addressed, postpaid envelope, or if not so posted, on the date of delivery.” [emphasis added].
Based on the record evidence before the Court, it is an undisputed fact that USAA mailed the $25.75 check to the Plaintiff’s attorney on October 21, 2009. Thus, the policy benefits exhausted on the date USAA mailed that draft. USAA would not be able to write additional drafts against the now exhausted $10,000.00 policy benefits, without exceeding the policy benefits. It is of no moment that the remaining $25.75 has not been deposited by the Plaintiff. Pursuant to the Statute, payment in response to the pre-suit demand letter is considered made when the check was mailed, not when the check is cashed. USAA met its obligation under its contract and under the Florida’s PIP Statute, when it mailed the $25.75 draft — exhausting all remaining PIP benefits — in response to the pre-suit demand letter.
This Court also finds that USAA did not act in bad-faith or improperly handle the down-code of CPT code 99214 to CPT Code 99213 in this case. Florida Statutes §627.756(5)(b)(1) states in pertinent part: An insurer or insured is not required to pay a claim or charges. . . (e) For any treatment or service that is upcoded, or that is unbundled when such treatment or services should be bundled, in accordance with paragraph (d). To facilitate prompt payment of lawful services, an insurer may change codes that it determines to have been improperly or incorrectly upcoded or unbundled, and may make payment based on the changed codes, without affecting the right of the provider to dispute the change by the insurer, provided that before doing so, the insurer must contact the health care provider and discuss the reasons for the insurer’s change and the health care provider’s reason for the coding, or make a reasonable good faith effort to do so, as documented in the insurer’s file; [emphasis added].
Based on the record evidence and specifically the deposition testimony of the Plaintiff’s person with the most knowledge, Robin Fielding, and USAA’s adjuster with the most knowledge, Donald Lehman, there is no dispute that USAA acted in accordance with the relevant portion of the Statute in processing the down-code. The depositions revealed that the Plaintiff was contacted prior to the down-code, and that contact is documented in the file of the insurer and the Plaintiffs’ own file.
Finally, the Plaintiff contends that USAA acted improperly when it applied a PPO negotiated rate to the Plaintiff’s bills in this case and, therefore, the benefits were not properly exhausted, or were exhausted in bad-faith. This Court disagrees. In coming to its conclusion this Court relies on the Supreme Court of Florida decision on this issue. See Allstate Insurance Company v. Holy Cross Hospital, Inc., 961 So. 2d 328 (Fla. 2007). Moreover, after review of the record, there is absolutely no evidence that USAA acted improperly or in bad-faith when it applied the negotiated, agreed upon, TRPN PPO rate to the Plaintiff’s bills in this case.
The record is clear that the Plaintiff (Robin Fielding, the CEO of the Plaintiff signed the agreement on behalf of the Plaintiff) voluntarily signed the TRPN PPO agreement. Ms. Fielding testifies that before signing the agreement, she read it, understood and agreed to the terms of that agreement. William Hurley, lead Counsel for TRPN, filed an affidavit stating that USAA was a member of the TRPN PPO network and was, therefore, able to access the reductions pursuant to the TRPN PPO agreement with the Plaintiff. The Plaintiff cannot now contend that it was unaware that USAA was a member of the TRPN network, and did not agree to take reductions to their bills for purposes of Auto and PIP related injuries that USAA would submit. Ms. Fielding has been the CEO of the Plaintiff — an 85 employee facility — for over 14 years and testified that she read, understood, and agreed to the TRPN agreement when she signed it.
Considering the foregoing, this Court finds that USAA acted in accordance with the terms of the TRPN PPO contract and its contract of insurance, in good-faith, when processing the Plaintiff’s bills in this case. USAA met its obligation under its contract and under the Statute, when it mailed the $25.75 draft — exhausting all remaining PIP benefits — in response to the pre-suit demand letter.
Accordingly, as the benefits under this policy of insurance exhausted, there can be nothing further due and owing.
Based upon the foregoing, USAA CASUALTY INSURANCE COMPANY’S Motion for Final Summary Judgment is hereby GRANTED;
The Defendant shall go hence forth without day.
This Court reserves jurisdiction to award attorney’s fees and costs.
