24 Fla. L. Weekly Supp. 466a
Online Reference: FLWSUPP 2406ADLEInsurance — Personal injury protection — Coverage — Medical expenses — Where medical provider could have billed service as HCPCS code that is reimbursable under Medicare fee schedule but instead chose to bill service as CPT code that is not reimbursable under Medicare fee schedule, insurer correctly reimbursed code as billed pursuant to workers’ compensation fee schedule
INJURY TREATMENT CENTER OF CORAL SPRINGS, INC., a/a/o Alec Adler, Plaintiff, v. GARRISON PROPERTY AND CASUALTY INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 15-005569. June 24, 2016. Stephen J. Zaccor, Judge. Division 54. Counsel: Robert A. Trilling, Boca Raton, for Plaintiff. Scott W. Dutton, Dutton Law Group, P.A., Tampa, for Defendant.
ORDER ON DEFENDANT’S MOTIONFOR SUMMARY JUDGMENT
This cause came before the court on June 21, 2016 on Defendant’s Motion for Summary Judgment. This is a breach of contract case for underpaid PIP benefits and involves Chiropractic services rendered by Injury Treatment Center of Coral Springs (hereinafter the Plaintiff). Garrison Property and Casualty Insurance Company (hereinafter the Defendant) paid the services in question pursuant to the Worker’s Compensation fee schedule.
After reviewing the pleadings, affidavits, depositions, evidence, the rest of the record, and after hearing argument of counsel for the parties, the court finds no issue of material fact and hereby grants Summary Judgment in favor of the Defendant.
ANALYSIS AND FINDINGS OF FACT
Both parties agree there are no factual disputes. “When the material facts are undisputed, they form a question of law which the trial court is empowered to decide on a motion for summary judgment.” Richmond v. Florida Power & Light Co., 58 So.2d 687 (Fla. 1952).
The Plaintiff provided various services to the insured from April 20, 2012 through April 26, 2012 and billed the Defendant on standard Health Insurance Claim Forms. The Defendant paid the bills pursuant to the Medicare Fee Schedule1 except for CPT code 97014 which was paid pursuant to the Worker’s Compensation Fee Schedule.2 CPT Code 97014 was reimbursed pursuant to the Worker’s Compensation Fee Schedule because the Center for Medicare and Medicaid Services did not price that code. The Defendant provided Explanations of Review (EOR) explaining the decision to pay CPT Code 97014 pursuant to Worker’s Compensation.
The Plaintiff issued a pre-suit demand letter claiming $1,419.20 was due and owing. A billing ledger was attached that included multiple CPT Codes including 97014. The Plaintiff filed a two count complaint alleging breach of contract in Count I. No CPT Codes are listed in the complaint.
The Defendant maintains they are entitled to summary judgment because they paid the submitted bills according to the appropriate fee schedules. The Plaintiff maintains they should have been reimbursed pursuant to the Medicare fee schedule because the service they billed under CPT Code 97014 is reimbursable pursuant to the Medicare Fee Schedule if billed as Healthcare Common Procedure Coding System (HCPCS) G0283.
The insurance policy at issue provides:
INSURING AGREEMENT
We will pay in accordance with the Florida Motor Vehicle No-Fault Law, to or for the benefit of the covered person:
1. 80% of medical benefits, and. . .
The policy defines Medical Benefits as “reasonable fees for medically necessary surgical, medical, x-ray, dental, and rehabilitative services. . .” Florida Statute 627.736(5)(d) provides:
All statements and bills for medical services rendered by a physician, hospital, clinic, or other person or institution shall be submitted to the insurer on a properly completed Centers for Medicare and Medicaid Services (CMS) 1500 form, UB 92 forms, or any other standard form approved by the office or adopted by the commission for purposes of this paragraph. All billings for such services rendered by providers must, to the extent applicable, follow the Physicians’ Current Procedural Terminology (CPT) or Healthcare Correct Procedural Coding System (HCPCS), or ICD-9 in effect for the year in which services are rendered and comply with the CMS 1500 form instructions, the American Medical Association CPT Editorial Panel, and the HCPCS. . . In determining compliance with applicable CPT and HCPCS coding, guidance shall be provided by the Physicians’ Current Procedural Terminology (CPT) or the Healthcare Correct Procedural Coding System (HCPCS) in effect for the year in which services were rendered, the Office of the Inspector General, Physicians Compliance Guidelines, and other authoritative treatises designated by rule by the Agency for Health Care Administration. . . For purposes of paragraph (4)(b), an insurer is not considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph and are properly completed in their entirety as to all material provisions, with all relevant information being provided therein.
Therefore, the Defendant contracted to reimburse 80% of medically necessary services they were timely notified of, if the charges were properly billed on a CMS 1500 form. The Defendant is not responsible for payment if the bills do not contain “all relevant information.” Id.
In the case at bar at the Defendant was timely notified by way of CMS 1500 forms that reimbursement for CPT Code 97014 was due and owing. The Plaintiff did not, although they could have, bill for HCPCS G0283. The Defendant reimbursed the Plaintiff according to the Worker’s Compensation Fee Schedule and notified the Plaintiff by way of an EOR of the reason for the payment. In response, the Plaintiff issued a pre-suit demand letter once again listing CPT Code 97014, not HCPCS G0283, as a disputed reimbursement. The Plaintiff now argues the Defendant is in breach of the insurance contract because they did not pay for a service that was not billed. They maintain the Plaintiff should have paid for HCPCS G0283 even though it was not billed. However, that is not what the insurance contract nor the statute require. According to §627.736(5)(d), the Plaintiff could have billed HCPCS G0283 but they did not. The Defendant paid, pursuant to the insurance policy, the codes that were billed. It cannot be said they breached the contract under these circumstances.
Accordingly, the Defendant’s Motion for Summary Judgment as to billed CPT Codes 97014 is GRANTED.
__________________
1The Plaintiff disputes the Defendant is entitled to pay at the fee schedule however, that issue is not currently before the court. For purposes of the issue at hand it will be assumed the Defendant may use the fee schedule.
2The Workmen’s Compensation Fee Schedule reimburses at a lower rate than the Medicare Part B Fee Schedule.
