23 Fla. L. Weekly Supp. 570a
Online Reference: FLWSUPP 2306PEREInsurance — Personal injury protection — Coverage — Lawfully rendered services — Medical provider’s submission of claim that included bills with rendering provider identification number of individual who had been barred from practicing medicine over one year prior to dates of treatment amounts to unlawful treatment or false and misleading statement, thus invalidating entire claim
DORAL MEDICAL REHAB CENTER, INC., A/A/O FERNANDO PEREZ, Plaintiff, v. PROGRESSIVE EXPRESS INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami Dade County, Civil Division. Case No. 2014-11988-CC-05 02. November 10, 2015. Motion for Rehearing Denied November 30, 2015. Honorable Teretha Lundy Thomas, Judge. Counsel: Jerome LaTorre, Law Offices of Gonzalez and Associates, Miami, for Plaintiff. Michael P. Hughes and Camille Riviere, Law Offices of Camille D. Riviere, Medley, for Defendant.
AFFIRMED. FLWSUPP 2701PERE
ORDER GRANTING DEFENDANT’S MOTIONFOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court for consideration of the Defendant’s Motion for Final Summary Judgment (filed on or about 10/01/15), and the Court having reviewed the Motion, having considered argument of counsel, and having been sufficiently advised in the premises, the Court finds as follows:
1. This case involves a disputed claim for personal injury protection benefits.
2. Plaintiff Medical provider submitted medical bills (HCFA form CMS 1500, version (08/05)) requesting payment for personal injury protection benefits as the result of a motor vehicle accident on 10/04/13.
3. The medical bills submitted included dates of service 10/08/13 through 11/15/2013.
4. These medical bills were submitted indicating that Ramiro J. Abaunza had rendered treatment for dates of service inclusive of dates 11/05/13 through 11/15/13 via including the NPI number 116480646 (Ramiro J. Abaunza’s NPI number) in box 24J (HCFA form CMS 1500), entitled “rendering provider id”.
5. Ramiro J. Abaunza offered to voluntarily relinquish his license to practice medicine in the State of Florida effective immediately as of April 30, 2012. This offer and its terms were subsequently adopted by Official action of the State of Florida Board of Medicine on August 17, 2012.
6. This court has taken judicial notice of the Department of Health (DOH) Case No. 2011-07524 Official Action of the State of Florida Board of Medicine (wherein the State of Florida accepts Ramiro Abaunza’s license relinquishment).
7. Ramiro J. Abaunza was not licensed and was prohibited from participating in the practice of medicine in the State of Florida over one year prior to the dates of service in the underlying lawsuit.
This case concerns application of Florida Statute §627.736(5)(b)(1)(b). Florida Statute §627.736(5)(b)(l)(b) provides: “An insurer or insured is not required to pay a claim or charges: For any service or treatment that was not lawful at the time rendered.” The words “Lawful or Lawfully” are defined by Florida Statutes § 627.732(10) to mean “in substantial compliance with all relevant applicable criminal, civil, and administrative requirements of state and federal law related to the provision of medical services and treatment.”
The case also sub judice concerns application of Florida Statutes § 627.736(5)(b)(l)(c). This statute provides that “[a]n insurer or insured is not required to play a claim or charges: . . .[t]o any person who knowingly submits a false or misleading statement relating to the claim or charges.” The word “Knowingly” is defined by Florida Statutes § 627.732(10) to mean that a “person, with respect to information, has actual knowledge of the information; acts in deliberate ignorance of the truth or falsity of the information; or acts in reckless disregard of the information, and proof of specific intent to defraud is not required.”
Plaintiff submitted medical bills (HCFA form CMS 1500) for dates of service inclusive of 11/05/13 to 11/15/13 containing the rendering provider identification number of an individual who was no longer licensed to practice medicine in the State of Florida. The Defendant contends that this amounts to either: unlawful treatment (which is inherently unreasonable as well as unlawful under Fla. Stat. 627.736(5)(b)(l)(b), and thus non-compensable), or amounts to a false or misleading statement under § 627.736(5)(b)(1)(c) because it incorrectly represents that: Ramiro Abaunza was licensed to perform said services at the time of treatment, and that he had in fact performed the services. The Defendant contended that the Plaintiff must have known the aforementioned statements were false, or acted in reckless disregard for the truth/falsity of such statements in submitting said medical bills due to the fact that Ramiro Abaunza had voluntarily relinquished his license over one year prior to the underlying dates of service. Based on these arguments, the Defendant claims that it may deny every bill from this provider in accordance with the rationale of Chiropractic One, Inc. v. State Farm Mut. Auto. Ins. Co., 92 So.3d 871 (Fla. 5th DCA 2012) [37 Fla. L. Weekly D1565a] which indicates that an entire claim may be denied due to submission of one false/misleading charge by a provider.
This Court agrees with Defendant’s position and finds that submitting a single HCFA CMS form 1500, with the rendering provider identification number of an unlicensed individual in box 24j here amounts to either unlawful treatment, or a false and misleading statement, thus invalidating the entire claim.
ORDERED that Defendant’s Motion for Final Summary Judgment is GRANTED.
