18 Fla. L. Weekly Supp. 490a
Online Reference: FLWSUPP 1805MEDI
Insurance — Personal injury protection — Coverage — Policy that provides that insurer will pay reasonable reimbursement amount in accordance with No-Fault Act and specifies that insurer will not pay any charge No-Fault Act does not require it to pay or any charge that exceeds amount No-Fault Act allows to be charged authorizes insurer to use fee schedule limits in PIP statute — Outpatient Prospective Payment System cap is applicable to reimbursement under PIP statute
V&T INVESTMENT PARTNERS d/b/a MEDVIEW IMAGING a/a/o JAIME MEDINA, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 18th Judicial Circuit in and for Seminole County. Case No. 2010-SC-001045. February 16, 2011. Donald L. Marblestone, Judge. Counsel: John L. Morrow and Matthew J. Corker, Conroy, Simberg, Ganon, Krevans, Abel, Lurvey, Morrow, & Schefer, P.A., Orlando, for Defendant.
FINAL JUDGMENT FOR STATE FARM
THIS MATTER came before the court on competing motions for summary judgment filed by Plaintiff, V&T INVESTMENT PARTNERS d/b/a MEDVIEW IMAGING a/a/o JAIME MEDINA and STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY. The Court having heard argument on December 9, 2010, and based upon a review of the undisputed facts, the filings by the parties and arguments made by the respective counsel, it is
ORDERED and ADJUDGED that
1. Plaintiff’s Motion for Summary Judgment is DENIED.
2. Defendant’s Motion for Summary Judgment is GRANTED.
FACTS
The facts in this case are not in dispute:
1. The above-captioned action seeks unpaid personal injury protection benefits stemming from an automobile accident that occurred on October 11, 2009.
2. On the date of the accident, Jaime Medina was covered by a policy of automobile insurance which provided, inter alia, $10,000.00 in personal injury protection benefits with State Farm under policy number 2804-630-59; Claim number 59-A370-436 was assigned to her claim.
3. On October 30, 2009, State Farm’s insured received services at Medview Imaging which included CPT Code 72141, which is an MRI of the cervical spine without contrast material.
4. Plaintiff submitted its bill for services which was received by State Farm on November 12, 2009. The total amount submitted for CPT Code 72141 was $1,250.00.
5. On November 16, 2009, State Farm made payment to Medview Imaging in the amount of $674.91.
6. On November 16, 2009 along with payment for services rendered on October 30, 2009, State Farm sent to Plaintiff an explanation of review which detailed why State Farm was paying the amount it did.
7. On March 8, 2010, Plaintiff dispatched a demand letter to State Farm seeking payment of the principle amount of $144.16; it was received by State Farm on March 12, 2010.
8. On April 6, 2010, State Farm responded to the demand letter asserting that State Farm paid properly under Medicare Part B and Fla. Stat. §627.736.
ISSUES DECIDED
The issues in this case required the Court to interpret State Farm’s policy, Fla. Stat.§627.736 and authoritative materials filed by the parties to make a determination of what the phrase “allowable amount under the participating physician fee schedule of Medicare Part B” means, what the “allowable amount” is for CPT code 72141, whether State Farm paid the correct amount; and, whether State Farm’s policy allows use of the fee schedule in §(5).
POSITIONS OF THE PARTIES
Plaintiff contends that the language of State Farm’s contract does not allow State Farm to use the fee schedule in Fla.Stat.§627.736(5), citing Nichols v. State Farm, 21 So.3d 904 (Fla. 5th DCA 2009) [34 Fla. L. Weekly D2275b] as controlling president (See page 6 of Plaintiff’s Amended Motion for Summary Judgment dated October 25, 2010).
Alternatively, it is Plaintiff’s position that Fla. Stat. §627.736(5)(a) does not allow PIP insurers to limit payments using Medicare Part B’s OPPS payment cap.
State Farm contends that its policy of insurance permits it to take into account in making reimbursements the fee schedules set forth in Fla. Stat. § 627.736(5). State Farm also contends that Florida Statutes §627.736(5), entitled “Charges for Treatment of Injured Persons”, incorporates Medicare Part B fee schedules, payment limitations and guidelines. State Farm asserts that the bills submitted to Defendant for payment should be adjusted in the same manner as if the bill were being adjusted by the Centers for Medicare and Medicaid Services (CMS), including all provisions of the Medicare benefit policy manuals, with the exception of the two (2) specific exclusions as set forth in 627.736(5)(a)(4). State Farm therefore asserts that “the allowable amount” is that amount that Medicare would pay to one of its participating physicians using the fee schedule and payment limitations in place on the date of service. This means that if CMS Medicare Part B adjusts the claim with the OPPS payment limitation, that end number is the “allowable amount.”
RULING
The Court rules that State Farm’s insurance policy provides that State Farm will pay a “reasonable” reimbursement amount in accordance with the No-Fault Act. The policy’s endorsement also references what will be considered to determine a reasonable charge. It states:
“5. NO-FAULT COVERAGE — COVERAGE P
b. Item 1. of What We Pay is change to read
1. Medical Expenses. 80% of all reasonable expenses incurred for:
a. medically necessary medical. . .
To determine whether a charge is reasonable we may consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state medical fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service, treatment or supply.
We will not pay any chare that the No-Fault Act does not require us to pay, or the amount of any charge that exceeds the amount the No-Fault Act allows to be charged.”
The policy is unambiguous, and under it, State Farm is authorized to use the fee schedule limits expressed in §627.736(5). See also, Fla. Stat. §627.7405.
The Court believes Nichols v. State Farm , 21 So.3d 904 (Fla. 5th DCA 2009) [34 Fla. L. Weekly D2275b] cited by Plaintiff, to be distinguishable and not controlling on the issues in this case.
Turning to the appropriate amount to charge pursuant to the participating physicians fee schedule, the Court concludes that “the allowable amount” under the participating physician fee schedule of Medicare Part B for CPT code 72141 for the 2009 treatment is $421.82. That amount constitutes the amount that Medicare would have allowed as reimbursement for the same treatment on the same date. State Farm paid 80% of $843.64 ($421.82 x 200%), and therefore, it paid the correct amount.
Lastly, it is clear to the Court that the inclusion of §627.736(5)(a)(4) which excepts out only two sections of the Medicare system, that the legislature did not want to include in Florida Personal Injury Protection Law, means the legislature adopted the Medicare pay system and excluded out only those two sections that they did not want to apply to Florida Law. This means that all other Medicare guidelines, rules, payment limitations and regulations should apply to subsection 5, which would include the Medicare Part B OPPS payment caps.
Therefore, Final Judgment is hereby entered in favor of State Farm Mutual Automobile Insurance Company and against V&T Investment Partners d/b/a Medview Imaging a/a/o Jaime Medina. Plaintiff, V&T Investment Partners d/b/a Medview Imaging a/a/o Jaime Medina, shall take nothing from this action and State Farm Mutual Automobile Insurance Company shall go hence without day.
This Court reserved jurisdiction to award costs and attorneys fees upon timely motion.
