18 Fla. L. Weekly Supp. 80b
Online Reference: FLWSUPP 1801PULL
Insurance — Personal injury protection — Coverage — Medical expenses — MRI — PIP statute does not authorize insurer to utilize Medicare’s Hospital Outpatient Prospective Payment System limitations or any other limitations not expressly described in PIP statute when determining amounts due for MRI services provided to PIP insured in non-emergency, non-hospital setting
CENTRAL IMAGING OPEN MRI, INC., as assignee of Gene Pullen, Plaintiff(s), vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant(s). County Court, 6th Judicial Circuit in and for Pinellas County, Small Claims Division. Case Nos. 09-4246SC-SPC, 09-8275SC-SPC. August 5, 2010. Kathleen T. Hessinger, Judge. Counsel: Marc B. Nussbaum, Reeder & Nussbaum, P.A., St. Petersburg, for Plaintiff. David B. Kampf, Ramey & Kampf, P.A., Tampa, for Defendant.
ORDER CONSOLIDATING CASE NO. 09-8275 SC WITH09-4246 SC, ORDER GRANTING PLAINTIFF’S MOTIONFOR SUMMARY JUDGMENT AND DENYINGDEFENDANT’S MOTION FOR SUMMARY JUDGMENT
This Cause came before this Court on Plaintiff’s Motion for Summary Judgment, Defendant’s Motion for Summary Judgment, and ore tenus Motion to Consolidate case no. 09-8275SC with case no. 09-4246SC, with the Parties present, through counsel, and this Court having heard argument, reviewed the many documents, and case law, and being otherwise advised of the premises, it is hereby Ordered and Adjudged as follows,
1. The ore tenus Motion to Consolidate case no. 09-8275SC with case no. 09-4246SC is GRANTED as both cases address the same Plaintiff and assignee, the same Defendant, and the same issues. Each case involves a different date of service.
2. The Parties also filed competing Motions for Summary Judgment addressing the proper amount to be paid by Defendant according to §627.736(5)(a) 2.f., Fla. Stat.
3. Plaintiff claims that Defendant is paying for MRI services performed by Plaintiff at a lower amount than allowable in the statute. Defendant claims, that in January 2007, the federal government capped the Medicare payment for outpatient services under a system called the Outpatient Prospective Payment System (OPPS). Plaintiff argues that this is a limitation, and not the allowable amount under the participating physicians schedule of Medicare Part B.
4. The payment of the bill at issue, in each case, rests on the plain meaning of the §627.736(5)(a) 2.f., Fla. Stat.
5. Section 627.736(5)(a)2.f., Fla. Stat. states, in pertinent part, “[f]or all other medical services, supplies, and care, 200 percent of the allowable amount under the participating physicians schedule of Medicare Part B.” The plain reading of the statute states that the insurer is to pay 200 percent of the allowable amount of the participating physicians schedule. It does not state that the insurer can pay the outpatient prospective payment amount or any other limitation on the participating physicians schedule.
6. The full reading of §627.736(5)(a)2 reflects that the legislature was aware of Medicare prospective payment schedules and other limitations on the fee schedule. Section 627.736(5)(a)2.d., Fla. Stat. (2009) states, “[f]or hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services.” (emphasis added) As the legislature referenced prospective payment in subsection (5)(a)2.d., it stands to reason that the legislature would have referenced the prospective payment in (5)(a)2.f. if that was the schedule for which the insurers’ were to base their payments of the applicable services.
7. Also, the plain reading of §627.736(5)(a)3, Fla. Stat. (2009) reflects that the OPPS was not to be applicable under §627.736(5)(a)2.f., Fla. Stat. This section states,
For purposes of subparagraph 2., the applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect at the time the services, supplies, or care was rendered and for the area in which such services were rendered, except that it may not be less than the allowable amount under the participating physicians schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B. (emphasis added) §627.736(5)(a)3, Fla. Stat. (2009)
This subparagraph distinguishes fee schedules and payment limitations. OPPS is a payment limitation, not a fee schedule. The applicable section, in this matter, §627.736(5)(a)2.f., Fla. Stat., specifically states “the participating physician schedule.” As such, the OPPS payment limitation relied upon by Defendant is not applicable to payment for services, supplies and care under §627.736(5)(a)2.f., Fla. Stat.
8. Based on this Court’s reading of the complete subparagraph, §627.736(5)(a)2, Fla. Stat., this issue is not as complicated as the many documents and arguments provided by the Parties make it appear to be. The statute is not ambiguous and plainly states the MRI services are to be paid at 200 percent of the allowable amount under the participating physicians schedule of Medicare Part B. It does not say, or even suggest, that the Outpatient Prospective Payment System (OPPS) limitation is applicable.
9. When the plain language of the statute is clear and unambiguous and conveys a clear and definite meaning, there is no occasion for resorting to the rules of statutory interpretation and construction; the statute must be given its plain and obvious meaning. The Courts are without power to construe an unambiguous statute in a way which would extend, modify, or limit, its express term or its reasonable and obvious implication. To do so would be an abrogation of legislative power. Holly v. Auld, 450 So. 2d 217, 219 (Fla. 1984).
It is therefore Ordered and Adjudged that Plaintiff’s Motion for Summary Judgment is GRANTED and Defendant’s Motion for Summary Judgment is DENIED. As this Court is not aware if this is the only issue in this matter, this is not a final summary judgment. This Court also orders that case no. 09-8275SC is consolidated with case no. 09-4246SC and this order applies to both cases.
