21 Fla. L. Weekly Supp. 586a
Online Reference: FLWSUPP 2106BURTInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy endorsement that specifically states that insurer will pay 80% of schedule of maximum charges contained in section 627.736(5)(A)2 allows insurer to apply permissive statutory fee schedules and limitations
SOUTHSIDE CHIROPRACTIC CENTRE, INC. A/A/O TERRI BURT, Plaintiff, vs. MERCURY INSURANCE COMPANY OF FLORIDA, Defendant. County Court, 17th Judicial Circuit in and for Broward County, Civil Division. Case No. 13 11120 COCE 51. February 6, 2014. Honorable Martin R. Dishowitz, Judge. Counsel: Chris Tadros, Law Offices of Chris Tadros, P.A., Fort Lauderdale, for Plaintiff. Robert M. Albert, Law Offices of Shirejian & O’Hara, Aventura, for Defendant.
ORDER GRANTING DEFENDANT’S MOTIONFOR SUMMARY JUDGMENT REGARDINGLIMITING REIMBURSEMENT OF PROVIDER CHARGESIN ACCORDANCE WITH FEE SCHEDULES
MERCURY issued a Florida Personal Auto Policy, policy number 0901 05 1000592-51 to Terri Burt for the policy period June 2, 2012 through December 2, 2012. The policy provided, among other things, coverage for Personal Injury Protection (“PIP”) benefits and subject to the terms and conditions as contained in the policy and the “U-85 (11/2011)” endorsement to the policy.
The pertinent parts of Mercury’s U-85 (11/2011) Endorsement state:
5. Medical Benefits shall be payable at the lesser of:
a. 80% of the actual charge, or
b. 80% of the following schedule of maximum charges contained in Florida Statute §627.736(5)(a)2:
1. For emergency transport and treatment by providers licensed under Florida Statutes, Title 29, chapter 401, 200 percent of Medicare.
2. For emergency services and care provided by a hospital licensed under Florida Statutes, Title 29, chapter 395, 75 percent of the hospital’s usual and customary charges.
3. For emergency services and care as defined by Florida Statutes Title 29, s. 395.002(9) provided in a facility licensed under chapter 395 rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community.
4. For 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.
5. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.
6. For all other medical services, supplies, and care, 200 percent of the allowable amount under the participating physicians schedule of Medicare Part B. However, if such services, supplies, or care is not reimbursable under Medicare Part B, we may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation, as determined under Florida Statutes Title 31, s. 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided. Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation will not be reimbursed.
7. For purposes of subparagraph 5(b)(6), if a Current Procedural Terminology (CPT) code is not reimbursable under the participating physicians schedule of Medicare Part B at the time the services, supplies or care was rendered, we will limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation, as determined under Florida Statutes Title 31, s. 440.13 and rules adopted thereunder which are in effect at the time such services, supplies, or care is provided.
The inclusion of the PIP endorsement to the policy puts all parties on actual notice of MERCURY’S intention to utilize the fee schedules under the Florida No-Fault Law. The endorsement specifically states MERCURY will pay 80% of the following schedule of maximum charges contained in Florida Statute §627.736(5)(a)2.
On or about October 2, 2012, Terri Burt (the “Claimant”) was injured in an automobile accident. As a result of this accident, the claimant received medical treatment from Plaintiff. The claimant assigned her rights to PIP benefits to Plaintiff.
Plaintiff sent MERCURY bills for medical services rendered to the claimant as a result of the accident in the amount of $4,175.00. Plaintiff claimed 80% of this amount, $3,340.00, was owed under the Florida No-Fault Law as PIP benefits under MERCURY’S policy. However, MERCURY paid 80% of 200% of the benefits available under Medicare Part B, $1,900.16.
The Florida Supreme Court held in Geico General Ins. Co. v. Virtual Imaging Services, Inc., 38 Fla. L. Weekly S517a (Fla. July 3, 2013) that for an insurer to utilize the fee schedules and limitations set forth in Fla. Stat. §627.736(5)(a)(2) an insurer must provide in its insurance policy that it will utilize these statutory schedules and limitations.
Under the terms of MERCURY’S policy, MERCURY applied the applicable provisions of Fla. Stat. §627.736. That statute states, in pertinent part:
(5) CHARGES FOR TREATMENT OF INJURED PERSONS.
(a). . . . .
2. The insurer may limit reimbursement to 80 percent of the following schedule of maximum charges:
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f. For all other medical services, supplies, and care, 200 percent of the allowable amount under the participating physicians schedule of Medicare part B. . .
Applying the applicable terms of MERCURY’s policy and Fla. Stat. §627.736(5), MERCURY reduced the billed amount of $4,175.00 to $2,375.20. MERCURY issued payment to Plaintiff for 80% of that amount, $1,900.16.
MERCURY’s PIP endorsement permits MERCURY to apply the statutory fee schedules and limitations, in this case, 200% of Medicare Part B.
It is therefore ORDERED AND ADJUDGED Defendant’s Motion for Summary Judgment Regarding Limiting Reimbursement of Providers Charges in Accordance with Fee Schedules is hereby GRANTED.
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