24 Fla. L. Weekly Supp. 236a
Online Reference: FLWSUPP 2403MMADInsurance — Personal injury protection — Coverage — Medical expenses — In calculating amount of PIP benefits to reimburse under permissive statutory fee schedule, insurer erred in failing to consider 2.2% update to 2010 Medicare Part B Physician fee schedule mandated by Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, which is applicable to dates of service commencing on June 1, 2010
APPLE MEDICAL CENTER, LLC (A/A/O Morales, Maday), Plaintiff, v. STATE FARM FIRE AND CASUALTY COMPANY, Defendants. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 2015-3874-CC 23 (04). June 22, 2016. Jason Emilios Dimitris, Judge. Counsel: Robert B. Goldman, Florida Advocates, Dania Beach, for Plaintiff. Raquel Campos, Roig Lawyer, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FORSUMMARY JUDGMENT REGARDING PLAINTIFF’SENTITLEMENT TO REIMBURSEMENT BASED UPON THEPRESERVATION OF ACCESS TO CARE FOR MEDICAREBENEFICIARIES AND PENSION RELIEF ACT OF 2010
THIS CAUSE having come before the Court on May 31, 2016, upon Plaintiff’s Motion for Summary Judgment, and the Court having considered the motion and the summary judgment evidence, having heard argument of counsel and being otherwise fully advised, it is hereupon
ORDERED that Plaintiff’s Motion for Summary Judgment is GRANTED, for the reasons set forth herein.
FINDINGS OF FACT
1. On May 19, 2010, Maday Morales was a covered person under an automobile insurance policy with State Farm Fire and Casualty Company.
2. On May 19, 2010, Maday Morales was involved in a motor vehicle accident.
3. State Farm has no coverage defenses to the Claim arising out of Maday Morales’ May 19, 2010, automobile accident. State Farm afforded coverage and paid bills.
4. Plaintiff Apple Medical Center, LLC charged $600 for Dr. David Lehrman’s CPT Code 99205 June 29, 2010 comprehensive orthopedic consultation, examination and evaluation of Maday Morales.
5. State Farm did not approve Apple Medical’s $600 charge, determining the allowed amount for the 99205 procedure based upon 200% of the Participating Level of Medicare Part B fee schedule for the region in which the services were rendered. According to State Farm’s Explanation of Review, State Farm approved $421.78 for the 99205 procedure, which is exactly 200% of the $210.89 Non-Facility Price for a 99205 procedure performed in Miami, Florida, during the year 2010 but prior to June 1st of that year.1
6. According to the Centers for Medicare & Medicaid Services, the Non-Facility Price for a 99205 procedure performed in Miami, Florida, after June 1, 2010, as reflected in the 2010B Medicare Part B Physician Fee Schedule, is $215.53. 200% of the $215.53 Non-Facility Price for a 99205 procedure performed in Miami, Florida, after June 1, 2010, is $431.06.
7. The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 provided for a 2.2% update to the 2010 Medicare Part B Physician Fee Schedule, effective for dates of service June 1, 2010 through November 30, 2010.STANDARD
A moving party is entitled to Final Summary Judgment if the pleadings, depositions, answers to interrogatories and admissions on file, together with the affidavits, if any, conclusively show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law. Volusia County v. Aberdeen at Ormond Beach, L.P., 760 So. 2d 126, 130 (Fla. 2000) [25 Fla. L. Weekly S390a]. The burden is upon the moving party to show conclusively the complete absence of any genuine issue of material fact. Holl v. Talcott, 191 So. 2d 40, 43 (Fla. 1966).
The trial court must draw every possible inference in favor of the party against whom summary judgment is sought. Moore v. Morris, 475 So. 2d 666 (Fla. 1985). If the evidence raises any issues of material fact, or it is conflicting, or if it will permit different reasonable inferences, or if it tends to prove the issues, summary judgment cannot be granted. McDonald v. Florida Department of Transportation, 655 So. 2d 1164 (Fla. 4th DCA 1995) [20 Fla. L. Weekly D1141a].
Once the moving party meets its burden of showing conclusively the complete absence of any genuine issue of material fact, the burden shifts to the non-moving party. Holl, 191 So. 2d at 43-44.CONCLUSIONS OF LAW
The issue for the Court is whether the pleadings on file and record evidence establish that summary judgment should be granted regarding Apple Medical’s entitlement to reimbursement based upon the Medicare Physician Fee Schedule in effect as of June 29, 2010. The Court answers in the affirmative and grants Plaintiff’s summary judgment.
Pursuant to Section 627.736(5)(a)(3), Fla. Stat. (2010), where an insurer limits reimbursement to 80% of 200% of the allowable amount under the participating physicians schedule of Medicare Part B (the methodology described at Sec. 627.736(5)(a)(2)(f)), “the applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect at the time the services, supplies or care was rendered, except that it may not be less than the allowable amount under the participating physicians schedule of Medicare Part B for 2007 for medical services, supplies and care subject to Medicare Part B.”
The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 provided for a 2.2% update to the 2010 Medicare Part B Physician Fee Schedule, effective for dates of service June 1, 2010 through November 30, 2010. In approving $421.78 instead of $431.06 for the CPT Code 99205 procedure performed by Apple Medical on June 29, 2010, State Farm failed to give consideration to the 2.2% update to the 2010 Medicare Part B Physician Fee Schedule, as mandated by the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.
The statutory language of The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 regarding the required 2.2% update to the 2010 Medicare Part B Physician Fee Schedule for dates of service commencing on June 1, 2010 is clear, unambiguous and conveys a clear and definite meaning, and the statute “must be given its plain and obvious meaning.” Knowles v. Beverly Enterprises-Florida, Inc., 898 So. 2d 1 (Fla. 2004) [29 Fla. L. Weekly S788a]; Dadeland Depot, Inc. v. St. Paul Fire and Marine Ins. Co., 945 So. 2d 1216 (Fla. 2006) [31 Fla. L. Weekly S882a] (“If the language of a statute or rule is plain and unambiguous, it must be enforced according to its plain meaning.”)
Accordingly, State Farm is precluded from using the 2010A Medicare Part B Physician Fee Schedule for a June 29, 2010 date of service, without regard to the 2.2% update to the 2010A Medicare Part B Physician Fee Schedule mandated by The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010. To the extent that State Farm sought to base its payment upon 200% of Medicare Part B, State Farm should have provided for a 2.2% update to the 2010A Medicare Part B Physician Fee Schedule and issued payment based upon $431.06 for the CPT Code 99205 procedure performed by Apple Medical on June 29, 2010. Having failed to provide for the 2.2% update to the 2010A Medicare Part B Fee Schedule as required by The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, which was in effect on June 29, 2010, STATE FARM paid less than the required minimum. It is therefore
ORDERED that Plaintiff’s motion for summary judgment is GRANTED. The Court reserves ruling on the issue of Plaintiff’s entitlement to reasonable attorneys’ fees and costs.
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1By Order entered May 31, 2016, this Court has taken judicial notice of the Medicare Part B Physician Fee Schedule and CMS.Gov, the federal government website managed by the Centers for Medicare & Medicaid Services, the entity that administers Medicare.
