22 Fla. L. Weekly Supp. 1165a
Online Reference: FLWSUPP 2210LASAInsurance — Personal injury protection — Coverage — Medical expenses — PIP policy that states that insurer will pay 80% of allowable amount under participating physician fee schedule of Medicare Part B clearly and unambiguously elects to limit reimbursement to permissive statutory fee schedule — Policy’s general references to coding policies and procedures does not clearly elect use of multiple procedure payment reduction rule that insurer used to reduce payment below permissive statutory fee schedule
PAN AM DIAGNOSTIC SERVICES, INC. A/A/O CRISTINA LASAGA, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 14-003289 SP 23 (03). April 30, 2015. Linda Singer Stein, Judge.
REVERSED. FLWSUPP 2701LASA
AMENDED ORDER GRANTING PLAINTIFF’SMOTION FOR PARTIAL SUMMARY JUDGMENTAND DENYING DEFENDANT’S MOTION FORSUMMARY JUDGMENT AS TOREIMBURSEMENT METHODOLOGY ONLY
This matter came before the Court on March 4, 2015, on the parties’ Cross Motions for Summary Judgment. Having read the motions, considered the argument of counsel present, reviewed all the applicable documents in the Court file, and those presented at the hearing by the attorneys, and having reviewed the evidence and case law provided by the attorneys and being otherwise advised in the premises, the Court GRANTS the Plaintiffs Motion for Summary Judgment and DENIES the Defendant State Farm Mutual Automobile Insurance Company’s Motion for Summary Judgment. Accordingly, it is herebyORDERED AND ADJUDGED:
That Plaintiffs Motion for Partial Summary Judgment is GRANTED and Defendant’s Motion for Summary Judgment is DENIED.Procedural Background
State Farm’s insured was injured in a car crash on August 29, 2013, and sought treatment with the Plaintiff/Medical provider. The provider accepted an assignment of the insured’s rights to recover PIP benefits, and performed two MRI exams on the insured on September 18, 2013.
In response to the provider’s claim for PIP benefits, State Farm sent a payment relying on the Medicare Multiple Procedure Payment Reduction rule (“MPPR”) to reduce payment to less than 200% of the allowable amount under the 2007 participating physicians fee schedule of Medicare Part B. The provider ultimately filed this suit for the difference.
The parties have filed cross-motions for summary judgment on the sufficiency of State Farm’s policy language as relates to the issue of whether State Farm’s 9810A policy form clearly and specifically elected the reimbursement methodology set forth in FS 627.736(5)(a)(1)(f), which requires reimbursement at 200% of the allowable amount under the participating physicians fee schedule of Medicare Part B, (except for two exceptions which do not apply in this case.), or clearly and specifically elected to pay according to a different, and lower, reimbursement method, the Multiple Procedure Payment Reduction, also known as MPPR.The Parties’ Arguments
The Plaintiff argues that State Farm’s 9810A policy form, at page 16, clearly states that State Farm will pay 80% of “the allowable amount under (1) The participating physicians fee schedule of Medicare Part B except as provided in sub-sub-paragraphs (II) and (III).” The exceptions provided in sub-sub-paragraphs (II) and (III) do not apply in this case. The policy further states that: “For purposes of the above, the applicable fee schedule or payment limitation in effect on March 1 of the year in which the services are rendered. . .except that it will not be less than the allowable amount under the applicable schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.”
State Farm argues that there is also language on page 16 of its 9810A policy stating: “We will limit payment of Medical Expenses described in the Insuring Agreement of this policy’s No-Fault Coverage to 80% of a properly billed and documented reasonable charge, but in no event will we pay more than 80% of the following No-Fault Act “schedule of maximum charges” including the use of Medicare coding policies and payment methodologies of the Federal Centers for Medicare and Medicaid Services, including applicable modifiers.” As well as page 5, where it states : “Reasonable Charge, which includes reasonable expense, means an amount to be determined by us to be reasonable in accordance with the No-Fault Act, considering one or more of the following:. . .7. Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services, including applicable modifiers, if the coding policy or payment methodology does not constitute a utilization limit.” State Farm argues that that language permits it to limit PIP reimbursements below the allowable amount under the 2007 Medicare Part B physicians fee schedule, based on the MPPR.
The Plaintiff filed suit for $269.47. This amount represents the difference between 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule and the amount paid by the Defendant. The Parties agree that the total amount claimed due by the Plaintiff, $1,773.04, represents 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule.Findings of fact
State Farm admitted that the assignor was covered at the time of the accident at issue by a policy issued by State Farm, and that that policy was in full force and effect. (State Farm’s Response to Plaintiffs Request for Admissions numbers 8 and 9). Both parties filed State Farm’s explanation of review in this case, showing when services were rendered, which services were rendered, and the amount State Farm paid for those services.
The Plaintiff, performed two MRIs. Specifically, Pan Am, performed CPT code 72141, which represents a cervical MRI, and CPT code 72148, which represents a lumbar MRI. The multiple diagnostic procedures (72141 & 72148) were performed by the Plaintiff upon the insured on the same day and during the same visit. The Defendant, State Farm, approved $672.80 for CPT code 72141 and $1,206.66 for CPT code 72148. State Farm paid 80% of the total approved amount for a total payment of $1,503.57.
The applicable fee schedule or payment limitation under Medicare for this claim is the 2007 Physician Fee Schedule. The parties also both filed State Farm’s 9810A policy form, agreeing that it is the operative policy in this case.Findings of law:
The construction of an insurance policy is a question of law for the court. See Jones v. Utica Mut. Ins. Co., 463 So. 2d 1153, 1157 (Fla. 1985). Such contracts are interpreted in accordance with the plain language of the policy, and any ambiguities are liberally construed in favor of the insured and strictly against the insurer as the drafter of the policy.
The Court finds that State Farm’s 9810A policy is clear and unambiguous regarding its election to pay pursuant to FS 627.726(5)(a)(1)(f). Through the policy language quoted above, State Farm clearly elected to pay no less than 80% of “the allowable amount under the 2007 Medicare Part B physicians fee schedule”. That phrase is patent on the face of the Defendant’s policy, and matches the current version of FS 627.736(5)(a)(1)(f.)
The Court further finds that State Farm’s policy does not clearly elect the MPPR, and that State Farm’s 9810A policy does not permit it to limit its reimbursement to the Plaintiff to less than 80% of the allowable amount under the 2007 Medicare Part B physicians fee schedule. The Court finds the policy controls. The Court is persuaded by the Plaintiff’s argument with regard to the reading of the policy; that the policy clearly and unambiguously elects the 200 Percent of the Medicare Part B Fee schedule method of reimbursement, and does not mention multiple fee schedules specifically enough to adopt. There is no clear election of the Multiple Procedure Rule or the MPPR reduction. The general references regarding Medicare coding policies and procedures discussed above on page 5 and 16 of policy are vague and ambiguous and do not clearly and unambiguously elect to pay pursuant to any other reimbursement methodology besides for the 80% of 200% of the 2007 Medicare Part B Physicians Fee Schedule method.
