18 Fla. L. Weekly Supp. 906b
Online Reference: FLWSUPP 1809JPER Insurance — Personal injury protection — Coverage — Consultation services — Where Medicare Part B fee schedule for consultation services no longer exists under own CPT code after 2010 change to Medicare CPT coding, but consultation services are still allowable Medicare Part B services under different coding, reimbursement is governed by Medicare fee schedule — Error to utilize workers’ compensation fee schedule to determine reimbursement as that fee schedule is only applicable to PIP claims when services are otherwise not reimbursable under Medicare Part B but are reimbursable under workers’ compensation fee schedule
JORGE PEREZ an insured individual by and through his assignee, JEFFREY TEDDER, M.D., P.A., Plaintiff(s), vs. ALLSTATE FIRE & CASUALTY INSURANCE COMPANY, a foreign corporation, Defendant(s). County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 10-CC-017058, Division I. June 20, 2011. Herbert M. Berkowitz, Judge. Counsel: Philip A. Friedman, FL Legal Group, Tampa, for Plaintiff. Anthony J. Parrino, Reynolds, Stowell, Parrino, P.A., St. Petersburg, for Defendant.
FINAL JUDGMENT GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT
THIS CAUSE came on for hearing before this Court on May 25, 2011, upon Plaintiff’s Motion for Summary Judgment as well as Defendant’s Motion for Summary Judgment. Counsel for both parties having appeared, and the Court, having considered argument of counsel, the record before it, and all submissions of the parties, and otherwise being fully advised in the premises, finds as follows:
1. Prior to January 1, 2010, the maximum allowable amount of reimbursement for consultation services such as those at bar was found in the applicable fee schedule or payment limitation under Medicare for consultation services in effect at the time services were rendered. Such payment limitation or fee schedule no longer exists for this specific service under its own CPT code, effective January 1, 2010, although payment for equivalent services still exist under different coding;
2. The nature of the medical services in question, i.e. consultation services, are allowable services under Medicare Part B for 2010, notwithstanding the Medicare change in the CPT coding effective January 1, 2010;
3. Therefore, the minimum allowable amount of reimbursement for medical services, such as those at bar, is that amount allowable under the participating physicians schedule of Medicare Part B for 2007.
4. Consequently, services rendered by Dr. Tedder are payable at a rate of 80% of 200% of the amount allowable for such services under Medicare Part B for 2007, in accordance with Fl Stat§627.736(5)(a) 2.f. as modified by Fl Stat §627.736(5)(a)3;
5. The Defendant’s utilization of the Workers Compensation maximum reimbursable allowance is misplaced, as use of the Workers Compensation rules to set reimbursement only come into effect under PIP when the services in question are otherwise not reimbursable under Medicare Part B but are reimbursable under Workers Compensation. If a service was not reimbursable under either, then such service would not be reimbursable under PIP as well. Clearly, consultation services as performed by Dr. Tedder are services contemplated for reimbursement by PIP, and so should be considered for what they are as opposed to how they are coded. Such services remain reimbursable under Medicare Part B, albeit as part of other services payable under CPT code. This, therefore, precludes the utilization of the Workers Compensation rules to determine reimbursement, as the Defendant did in this instance.
Ruling:
6. Count I of the Complaint seeks declaratory relief. The Court finds that Fl. Stat. §627.736(5) requires the application of the fee schedule under the participating physicians schedule of Medicare Part B for 2007 to be the proper standard for reimbursement for consultation services for such services as provided by Dr. Tedder after January 1, 2010, and as such the usual and customary charges for such services are payable at 80% of 200% of such amounts allowable under Medicare Part B for 2007.
7. Count II of the Complaint seeks damages, and the Court finds that Defendant assessed the claim pursuant to the Workers Compensation fee schedule at $241.00, and payable at 80%. This resulted in a payment of $192.80 plus interest, penalties and postage of an additional $30.15 for a total payment of $222.95. The proper assessment should have been at 80% of 200% of the relevant schedule for payment pursuant to Medicare Part B for 2007.
8. The rate under Medicare Part B for 2007 for these services was $219.30, and 200% of this amount is $438.60. This amount was due and owing at 80%, or $350.88. Defendant is entitled to credit for payment of $192.80, which leaves a balance due to the Plaintiff of $158.08, plus interest, penalties and postage. Because interest and penalties based on this increased amount will be more than the $30.15 paid previously, the Court reserves ruling on the amount of such interest and penalties as are now due, noting that Defendant will be entitled to a credit of $30.15 previously paid on those items.
9. Judgment on Count II of the Complaint is for the Plaintiff in the amount of $158.08 plus interest, penalties and postage if any, less $30.15, together with attorney fees as may be appropriate. The Court reserves jurisdiction on the matter of attorney fees, costs and all other matters consistent with this Final Judgment, and for all which let execution issue.
10. The Defendant’s Motion for Summary Judgment is DENIED for reasons consistent with the findings herein.
