20 Fla. L. Weekly Supp. 629a
Online Reference: FLWSUPP 2006RAMIInsurance — Personal injury protection — Coverage — Medical benefits — Diagnostic services — Reasonableness of charges — Discovery — Information regarding other types of insurance accepted by provider and reimbursement amounts that provider has agreed to accept from other insurance companies, including HMO and PPO agreements — Amount a medical provider contracts for with other providers, such as HMO or PPO setting, may be logically probative of the reasonableness of what is charged or reimbursed — Plaintiff ordered to provide for in camera inspection information regarding HMO and PPO agreements between plaintiff, or other entity through which plaintiff provided medical services, and any managed care provider, HMO, PPO, or others, in effect of dates of service at issue in this case
PEMBROKE PINES MRI (a/a/o Elixardo Ramirez), Plaintiff, vs. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 12-14670 COCE (53). March 18, 2013. Robert W. Lee, Judge. Counsel: Michael Leader, Fort Lauderdale, for Plaintiff. Adam Shapiro, Office of the General Counsel, United Automobile Insurance Company, Miami, for Defendant.
ORDER ON DEFENDANT’S MOTION TOCOMPEL BETTER ANSWERS TO DEFENDANT’SREASONABLENESS CHARGE REQUEST FORPRODUCTION AND DEFENDANT’S MOTION TODETERMINE THE SUFFICIENCY OFPLAINTIFF’S OBJECTIONS TO DEFENDANT’SFIRST REQUEST FOR ADMISSIONS
THIS CAUSE having come before the Court on March 11, 2013 on Defendant UNITED AUTOMOBILE INSURANCE COMPANY’S Motion to Compel Better Answers to Defendant’s Reasonableness Charge Request for Production and Motion to Determine the Sufficiency of Plaintiff’s Objections to Defendant’s First Request for Admissions and the Court having reviewed the motion, having heard argument of counsel, having reviewed relevant legal authority and being sufficiently advised in the premises, finds as follows:Background
This lawsuit arises out of a breach of contract action for Personal Injury Protection (“PIP”) Benefits regarding diagnostic services rendered by the Plaintiff PEMBROKE PINES MRI, INC. As stipulated by the Defendant at the hearing, the only issue remaining in this case is whether the diagnostic services provided by the Plaintiff were reasonable in price, and if not, what amount is reasonable.
Defendant propounded discovery upon Plaintiff consisting of a request for admissions and a “reasonableness charge” request for production seeking information regarding other types of insurance that Plaintiff accepts as well as the reimbursement amounts that Plaintiff has agreed to accept from other insurance carriers. More specifically, as it relates to Defendant’s First Request for Admissions, requests 2-6 requested that Plaintiff admit or deny as follows:
2. Admit that Plaintiff/provider accepts payments and/or provides services to other patients who are covered by an HMO during the same year in which the medical services that are subject of this lawsuit were rendered.
3. Admit that Plaintiff/provider accepts payments and/or provides services to other patients who are covered by a PPO during the same year in which the medical services that are subject of this lawsuit were rendered.
4. Admit that Plaintiff/provider accepts payments and/or provides services to other patients who are covered by Medicare during the same year in which the medical services that are subject of this lawsuit were rendered.
5. As it pertains to CPT codes 72141, 72148 and 73030, admit that the Plaintiff has accepted reimbursement amounts tendered by other insurance carriers in satisfaction of the claim that were less than or equal to the reimbursement amount allowed by Part B of the Medicare Fee Schedule during the same year in which the medical service that is subject of this lawsuit was rendered.
6. As it pertains to CPT codes 72141, 72148 and 73030, admit that the Plaintiff has accepted reimbursement amounts tendered by other insurance carriers in satisfaction of the claim that were less than or equal to the reimbursement amount allowed by Defendant during the same year in which the medical service that is subject of this lawsuit was rendered.
As it relates to Defendant’s Reasonableness Charge Request for Production, request 4 requested copies of all “HMO and PPO agreements between [Plaintiff] (or any entity through which [Plaintiff] provided medical services) and any managed care provider, HMO, PPO, or others, in effect on the dates of service at issue.” In response, Plaintiff raised various objections to the aforementioned requests.Conclusions of Law
Plaintiff has the burden of establishing that the medical bills at issue are reasonable. See Allstate Ins. Co. v. Derius, 773 So.2d 1190 (Fla. 4th DCA 2000) [25 Fla. L. Weekly D2730a]. Fla. Stat. §627.736(5)(a)(1) defines a “reasonable” charge as follows:
In no event, however, may such a charge be in excess of the amount the person or institution customarily charges for like services or supplies. With respect to a determination of whether a charge for a particular service, treatment, or otherwise is reasonable, consideration may be given to evidence of usual and customary charges and payments accepted by the provider involved in the dispute, and 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.
Evidence of a reasonable charge includes what a provider accepts, as well as “reimbursement levels in the community” and “various federal and state medical fee schedules applicable to automobile and other insurance coverages.” See Fla. Stat. §627.736(5)(a)(1) (2011). See also Allstate Ins. Co. v. Holy Cross Hosp., Inc., 961 So. 2d 328, 335 (Fla. 2007) [32 Fla. L. Weekly S453a] (finding that “[w]hat a provider customarily charges or has previously accepted are important factors for determining whether a fee is reasonable.”).
Florida Statute §627.736(5)(a) provides in pertinent part that the reasonableness of a charge is determined by looking at three things: (1) the usual and customary charges and payments accepted by the provider; (2) reimbursement levels in the community and various federal and state medical fee schedules applicable to motor vehicle and other coverages; and (3) other information relevant to the reasonableness of the reimbursement for the service, treatment, or supply. The Plaintiff argues that the information sought by Defendant does not fall into any of these categories.
Evidence is relevant on this issue if it is “logically probative.” Ehrhardt’s Florida Evidence §401.1 (2011). This is an issue of logic, rather than a mere issue of law. See Johnson v. State, 595 So.2d 132, 134 (Fla. 1st DCA 1992). The question for the Court is whether the amount that a medical provider contracts for with other providers (such as a HMO or PPO setting) may be logically probative of the reasonableness of what is charged or reimbursed. In light of the broad language now provided by the Florida Legislature, the Court finds that a jury may logically consider this evidence on the issue of whether the charge or reimbursement for that service is or is not reasonable. See Zabner v. Howard Johnson’s Inc. of Fla., 227 So.2d 543, 545 (Fla. 4th DCA 1969) (“[r]elevancy describes evidence that has a legitimate tendency to prove or disprove a given proposition”) (emphasis added). In the Court’s view, the Defendant’s arguments go more properly towards the weight to be given to this evidence, rather than whether the evidence should be inadmissible.
To be sure, the amount a provider contracts with HMOs and PPOs has typically been found not relevant to whether a particular medical charge is reasonable. Rather, the focus of reasonableness of a charge is the “prevailing cost” of services to patients not otherwise protected by contracted rates of reimbursement. See Leitinger v. DBart, Inc., 302 Wis.2d 110, 144 n.65, 73 N.W.2d 1, 18 n.65 (2007); Radvany v. Davis, 262 Va. 308, 551 S.E.2d 347, 348 (2001). This is because “[t]he modern health care system employs a myriad of health care finance arrangements. As part of the system, negotiated and contracted discounts between health care providers and insures are increasingly prevalent. Pursuant to these agreements, an insurer’s liability for the medical expenses billed to its insured is often satisfied at discounted rates, with the remainder being ‘written-off’ by the health care provider.” Koffman v. Leichtfuss, 246 Wis.2d 31, 44, 630 N.W.2d 201, 208 (2001). Indeed, these “finance arrangements” offer medical providers a steady stream of business so long as they are willing to accept the lower rate of payment. Medical providers offering services under PIP policies do not, however, have the benefit of such a volume of steady business. As a result, it has traditionally been misleading to consider these contracted rates when determining whether a provider’s charge is “reasonable.”
The Florida Legislature, however, has now changed this general rule as applied to payments under a PIP policy. In this instance, the Florida Legislature specifically provided that a wide variety of insurance coverages and reimbursement amounts may be considered. In enacting this statutory requirement, moreover, the Legislature further specifically provided that a jury may also consider “other evidence relevant to the reasonableness of the reimbursement.” Fla. Stat. §627.736(5)(a). The Court believes what a medical provider accepts under contracted arrangements may be relevant to whether the amount reimbursed is reasonable. Indeed, the Court believes that this is what the Legislature intended in providing such broad statutory language. For the same reason, under the same broad statutory language, a jury should be entitled to know what other medical providers in the community charge for the same service — it appears clearly relevant to the issue of the reasonableness of what an insurer reimburses.
Therefore, it is ORDERED AND ADJUDGED that Plaintiff PEMBROKE PINES MRI, INC. shall either admit or deny requests 2-6 of Defendant UNITED AUTOMOBILE INSURANCE COMPANY’S First Request for Admissions within twenty (20) days from the date of this Order.
It is further ORDER AND ADJUDGED that Plaintiff PEMBROKE PINES MRI, INC. shall provide under seal directly to this Honorable Court for in camera inspection the information regarding “HMO and PPO agreements between [Plaintiff] (or any entity through which [Plaintiff] provided medical services) and any managed care provider, HMO, PPO, or others, in effect on the dates of service at issue” sought in request 4 of Defendant UNITED AUTOMOBILE INSURANCE COMPANY’S Reasonableness Charge Request for Production within twenty (20) days from the date of this Order in order to evaluate what if any of the documents contain confidential information, and whether they otherwise have any information that may lead to the discovery of admissible evidence.
* * *
