20 Fla. L. Weekly Supp. 73a
Online Reference: FLWSUPP 2001ETIEInsurance — Personal injury protection — Affirmative defenses — CPT coding — Insurer was not entitled to deny payment of PIP benefits on ground that medical provider failed to submit claims coded in compliance with National Correct Coding Initiative — Demand letter was not defective where letter stated amount of demand and insurer’s response indicated it knew contents of demand
PHYSICIANS GROUP OF SARASOTA, LLC F/D/A PHYSICIANS GROUP, LLC A/A/O JEAN ETIENE, Plaintiff(s), vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant(s). County Court, 12th Judicial Circuit in and for Sarasota County. Case No. 2011 SC 3381 NC. October 3, 2012. Kimberly Bonner, Judge. Counsel: Yasmin Gilinsky, Law Office of Russel Lazega, Dania Beach, for Plaintiff. Kristan S. Coad, Conroy, Simberg, Ganon, Krevans, Able, Lurvey, Morrow & Scheffer, P.A., Tampa, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTIONFOR PARTIAL SUMMARY JUDGMENT(AS TO DEMAND LETTER AND CODING DEFENSES)
THIS CASE came before the Court on the Plaintiff, Physicians Group of Sarasota, LLC’s, Motion for Partial Summary Judgment. The Defendant has also filed a Motion for Partial Summary Judgment on the same issue. The Court has considered the arguments of Counsel, reviewed the applicable law, and finds as follows.
The present claim seeks damages under Florida Statue 627.736 for unpaid Personal Injury Protection claims submitted to the Defendant. The Defendant seeks partial summary judgment on two theories. First, it alleges that the Plaintiff’s demand letter was defective. Secondly, it alleges that the medical provider failed to follow certain coding requirements that fall under the Medicare fee schedule. Specifically, the Defendant alleges that on July 8th, 2008, the medical provider submitted claims with three separate treatment codes. The Defendant alleges that the provider should have placed a modifier on one of the codes, indicating that it was an extended service. Instead, the provider reported it separately with a different code. The treatment at issue included a pre-procedure exam, and an injection of medication for shoulder and neck pain. The Defendant also alleges that the demand letter was defective because it failed to provide sufficient information as to the amount of payment sought. The Court finds that the Defendant’s assertions as to the demand letter are without merit.
The Plaintiff alleges that the demand letter clearly stated the amount of the demand and that the Defendant’s response clearly indicates that they knew the contents of the demand. The Plaintiff alleges in its motion that the coding issue raised by the Defendant is without merit, in that the National Correct Coding Initiative (NCCI) does not apply to PIP cases.
In support of its Motion for Summary Judgment on this issue the Plaintiff relies upon the recent case of SOCC, PL d/b/a South Orange Wellness vs., State Farm Mutual Automobile Insurance Company 2012 WL 264384 Fla. 5th DCA 2012. This case addresses a nearly identical issue, as to the NCCI edits, and in this case the 5th DCA rejected the position taken by the present Defendant. The Court found that the legislature, in enacting and subsequently amending the PIP Statute, specifically did not intend to incorporate the NCCI edits into the Florida No Fault Statue.
The Defendant in this case attempts to distinguish the SOCC case by asserting that the denial in this case was not based upon NCCI edits but based upon the Medicare requirements. The Defendant bases its position in part upon its expert affidavit; however, upon review of this affidavit it is clear that the attesting physician consistently relies upon the NCCI manual in reaching her conclusion that the provider used inappropriate coding. Even assuming that this affidavit is admissible for purposes of a Motion for Summary Judgment, as it appears to provide a legal conclusion as opposed to asserting facts based upon personal knowledge, the Defendant’s assertion that the denial was based upon Medicare is belied by the fact that the NCCI edits follow from the Medicare schedule.
Therefore, it appears to this Court that the holding in SOCC is dispositive of this action.
Based upon the holding in SOCC, PL d/b/a South Orange Wellness vs. State Farm Mutual Automobile Insurance Company, the Court therefore Grants the Plaintiff’s Motion for Partial Summary Judgment as to the demand letter and coding defenses. The Defendant’s Motion for Partial Summary Judgment is Denied.
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