24 Fla. L. Weekly Supp. 766b
Online Reference: FLWSUPP 2409DEYInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Clear and unambiguous election by insurer — Insurer that incorporated Medicare fee schedule into PIP policy may utilize Medicare coding policies and payment methodologies, including Multiple Procedure Payment Reduction, to determine appropriate amount of reimbursement so long as methodology applied is not utilization limit — MPPR is payment methodology, not utilization limit
CORAL SPRINGS PHYSICIANS ASSOCIATE, INC., a/a/o Nixon Dey, Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 15-2440 (52). August 18, 2016. Giuseppina Miranda, Judge. Counsel: Matthew Emmanuel, Todd Landau, P.A., for Plaintiff. Kevin P. Sincerbox, Progressive PIP House Counsel, Fort Lauderdale, for Defendant.
FINAL SUMMARY JUDGMENTIN FAVOR OF DEFENDANT
THIS CAUSE having come before the Court on for hearing on June 16, 2016 on the Plaintiff’s Motion for Summary Judgment dated April 13, 2016 and Defendant’s cross Motion for Summary Judgment dated June 6, 2016, and the Court having reviewed the Motions, the entire Court file, and the relevant legal authorities; having heard argument; having made a thorough review of the matters filed of record; and having been sufficiently advised in the premises, the Court finds as follows:
A. Plaintiff stipulated that Defendant has properly incorporated the Medicare fee schedule into its policy as a limitation when paying benefits.
B. Additionally, this Court finds that the fee schedule has been properly incorporated into the policy by clear and unambiguous election of the fee schedule to limit reimbursement . This election is delineated in the “Personal Injury Protection Coverage Endorsement” section of the policy titled “Unreasonable or Unnecessary Medical Benefits”.
The policy specifically notifies the insured that:
“We will determine to be unreasonable any charges incurred that “exceed the maximum charges set forth in Section 627.736(5)(a)(1)(a through f) of the Florida motor Vehicle No-fault Law. . . we will limit reimbursement to, and pay no more than, 80 percent of the following schedule of maximum charges:
f. for all other medical services, supplies and care, 200 percent of the allowable amount under the participating physicians fee schedule of Medicare Part B . . .”
C. Plaintiff asserts, however, that Defendant has improperly utilized the Multiple Procedure Payment Reduction (hereafter referred to as “MPPR”) when calculating reimbursement of Plaintiff’s bills in violation of Fla. Stat. §627.736(5)(a)(2).
D. Plaintiff mainly relies on the ruling of Orthopedic Specialists (Kelli Serridge) v. Allstate Insurance Company, 177 So. 3d 19 (Fla. 4th DCA 2015)[40 Fla. L. Weekly D1918a] and focuses on the term “shall be subject to” in Defendant’s policy.
E. The pertinent part of the policy reads as follows:
“In determining the appropriate reimbursement under the applicable Medicare fee schedule, all reasonable, medically necessary, and covered charges for services, supplies and care submitted by physicians. . . or any other provider will be subject to the Center for Medical Services (CMS) coding policies and payment methodologies, including applicable modifiers. The CMS policies include, but are not limited to . . . Multiple Procedure Payment Reduction (MPPR). . .” (emphasis added).
F. This Court finds that the holding in Orthopedic Specialists does not apply to the case at bar because Defendant’s policy has clearly and unambiguously made an election of a payment limitation. Once the election is properly made, the insurer is free to utilize the Medicare coding policies and payment methodologies, including applicable modifiers to determine the appropriate amount of reimbursement for medical services so long as it does not constitute a utilization limit. See §627.736(5)(a)(3), Florida Statutes (2012).
G. This Court finds the MPPR to be a payment methodology and not a utilization limit. Therefore, the statute permits the use of the payment methodology once the fee schedule is properly elected.
Based on the foregoing, is hereby ORDERED AND ADJUDGED as follows: Plaintiff’s Motion for Final Summary Judgment is DENIED and Defendant’s Motion for Summary Judgment is GRANTED.
IT IS THEREFORE ORDERED AND ADJUDGED that Plaintiff, Coral Springs Physicians Associates, Inc., shall take nothing by this action. FINAL JUDGMENT is hereby entered in favor of the Defendant, Progressive American Insurance Company, and it shall go hence forth without day. The Court reserves jurisdiction determine entitlement to reasonable fees and costs.
