25 Fla. L. Weekly Supp. 69a
Online Reference: FLWSUPP 2501COLEInsurance — Personal injury protection — Discovery — Depositions — Scope of inquiry and documents to be produced at deposition of insurer’s corporate representative
FLAGLER HOSPITAL, INC, a Florida Corp. (a/a/o Cole, Johnnie), Plaintiff, v. SOUTHERN-OWNERS INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 12-SC-12268-0. March 22, 2017. Eric H. DuBois, Judge. Counsel: David Hwalek, Florida Advocates, Dania Beach, for Plaintiff. Ryan Sainz, Vernis & Bowling, Tampa, for Defendant.
ORDER ON DEFENDANT’S MOTION FORPROTECTIVE ORDER AND SUPPORTINGMEMORANDUM OF LAW
THIS CAUSE having come before this Court for hearing on March 10, 2017 on Defendant’s Motion for Protective Order and Supporting Memorandum of Law, and the Court having heard both parties’ arguments, reviewed case law presented by the parties at the hearing, and being otherwise advised in the premises, it is hereby
ORDERED AND ADJUDGED that:
The Defendant’s Motion for Protective Order requesting a limitation on the scope of questioning to exclude topics and documents is GRANTED in part, and DENIED in part, and the objections asserted therein are SUSTAINED in part and OVERRULED in part, as follows:
1. The Plaintiff shall be permitted to conduct the deposition of Defendant’s designated corporate representative and inquire regarding the following designated topics enumerated in the Notice of Taking Deposition Duces Tecum:
General information of the Claim.
Policy and coverage details of the Claim.
Whether the amount Plaintiff charged for performing the Relevant CPT Code Procedures was unreasonable and the basis, including any underlying data and data compilations, analysis, spreadsheet(s), formula(s), average(s), survey(s), research, information and investigation to support that determination.
Whether the amount Plaintiff charged for performing the Relevant CPT Code Procedures was not usual or customary, and the basis, including any underlying data and data compilations, analysis, spreadsheet(s), formula(s), average(s), survey(s), research, information and investigation to support that determination.
Other than the Medicare Fee schedule and calculations contained in Sec. 627.736(5)(a)(2)(f), Fla. Stat., all data or data compilations, analysis or analyses, spreadsheet(s), formula(s), average(s), survey(s), research, information, investigation(s) upon which Defendant has relied to dispute the reasonableness of the amounts charged by Plaintiff for performing the Relevant CPT Code Procedures.
All items that were considered by the Defendant in determining the reasonableness of Plaintiff’s charges and how each of these items was utilized by the Defendant in calculating the reimbursement amounts.
The method/methodology and calculations utilized in reducing the Plaintiff’s charges in this case to the allowed amount indicated in any Explanations of Review or Explanations of Benefits.
Whether the Defendant has undertaken any research, investigation, comparative studies, statistical analysis and/or surveys of medical providers in the Community who practice in the same specialty area as the Plaintiff, within two years of the medical services that were provided by the Plaintiff in this case, for the purpose of determining (a) the usual and customary charges of medical providers in the Community for the Relevant CPT Code Procedures and (b) a reasonable charge in the Community for the Relevant CPT Code Procedures.
The amounts charged by medical providers in the Community who practice in the same specialty area as the Plaintiff, for the Relevant CPT Code Procedures during the Relevant Period.
The amounts allowed by the Defendant for the charges of medical providers in the Community who practice in the same specialty area as the Plaintiff, for the Relevant CPT Code Procedures performed during the Relevant Period.
Reports/charts/audits to which Defendant is privy as it relates to amounts charged by medical providers in the Community who practice in the same specialty area as the Plaintiff, for the Relevant CPT Code Procedures performed during the Relevant Period.
The factual basis supporting the position that the Plaintiff did not charge a reasonable price for the medical services rendered to the Patient, including any evidence to support that position.
If Defendant contends that the medical services rendered by the Plaintiff to the Patient was not related to the Automobile Accident, the factual basis supporting that position, including any evidence to support that position.
If Defendant contends that the medical services rendered by the Plaintiff to the Patient was not medically necessary, the factual basis supporting that position, including any evidence to support that position.
If Defendant contends that the medical services rendered by the Plaintiff to the Patient was not medically necessary or not related to the Automobile Accident, all information and documentation in Defendant’s care, custody, control or possession, which pertains, refers or relates to the Automobile Accident, including but not limited to medical records and invoices from other medical providers, accident reports, damage estimates, invoices and repair bills, photographs, statements and transcripts of Examinations Under Oath.
The factual basis supporting each and every defense to payment asserted by Defendant as to the Claim.
The documents identified in the Duces Tecum portion of Plaintiff’s Notice of Taking Rule 1.310(B)(6) Deposition.
2. The Defendant shall produce to Plaintiff the following items enumerated in the Duces Tecum that is part of the Notice of Taking Rule 1.310(B)(6) Deposition:
The entire Personal Injury Protection (PIP) claim file (pre-litigation and post-litigation) maintained by Defendant, including but not limited to: any notes/records reflecting Defendant’s review of the Claim [this includes any adjuster notations from the beginning of the claim up until the date that the pre suit demand letter was received (any notations of attorney client communications may be redacted)]; copies of any and all checks to Plaintiff; explanation(s) of benefits/review related to Plaintiff’s medical services rendered to the Patient; Defendant’s most up-to-date PIP payout sheet, record of payment or other form showing all bills that have been submitted for payment (whether showing bills paid in full or paid at reduced rates) and documenting when payments were made of PIP benefits on the Claim, including any computerized records; each and every letter, communication or correspondence in which Defendant notified Plaintiff of its failure to comply with any statutorily or contractually imposed conditions precedent to payment or suit; any and all responses by Defendant to Plaintiff’s demand letter(s); and actions taken by Defendant on the Claim.
Copies of the Policy and Policy Declarations Page.
A copy of the Notification of Insured’s Rights as required by Fla. Stat. Sec. 627.7401 delivered by Defendant to the Insured (the “Notice”), including, but not limited to: the Notice, copies of any cover letter(s) or other correspondence accompanying the Notice and copies of any documents, papers or other forms or letters included with the Notice.
Any and all documents reflecting bills submitted by Plaintiff and the dates that the bills were received by Defendant under the Claim, including Plaintiff’s bills reflecting Defendant’s date stamps and Defendant’s logs showing date of receipt of the bills.
Any and all correspondence, documents, materials or other items regarding the medical reports and bills received from Plaintiff related to treatment provide to the Patient.
To the extent that they exist, any and all Independent Medical Examination (“IME”) requests and IME Reports related to the Patient.
To the extent that they exist, any and all Examinations Under Oath (“EUO”) requests, correspondence from the Defendant related to an EUO of the Patient, EUO transcripts related to the Patient or the Automobile Accident and any and all correspondence from any agencies hired by Defendant to schedule an EUO of the Patient, who were in attendance at the time of the scheduled EUO.
To the extent that they exist, any and all reports or medical opinions or records review conducted in connection with Plaintiff’s medical services rendered to the Patient.
Any and all statements taken by Defendant of any witnesses with regard to any fact relevant to any issues in this case, taken prior to the filing of the lawsuit in this matter.
Copies of any and all medical records and billing records of other Providers of medical treatment/MRI/x-rays rendered to the Patient in this Claim.
Documents evidencing damage to the vehicle in which the Patient was an occupant, resulting from the Automobile Accident, including but not limited to estimates of property damage, repair bills, photographs and accident reports.
Any and all reports or statements from any expert indicating that the treatment rendered by Plaintiff was not reasonable, not related or not necessary.
Any and all information in Defendant’s possession which Defendant reviewed or upon which Defendant relied in calculating the “reasonable amount” as defined in Fla. Stat. Sec. 627.736(5)(a)(1) for Plaintiff’s medical services rendered to the Patient.
Other than the Policy, Medicare Fee Schedule and calculations contained in Fla. Stat. Sec. 627.736(5)(a)(2)(b)], any and all proof (including but not limited to data and data compilations, mathematical calculations, statistical analyses, spreadsheet(s), formula(average(s), survey(s), research, information and investigation(s) upon which Defendant relies to dispute that the amounts charged by Plaintiff for the Relevant CPT Code Procedures were not reasonable charges.
To the extent that they exist, surveys of medical providers in the Community, that evidence, show or indicate the charges of medical providers in the Community for providing the Relevant CPT Code Procedures during the Relevant Period.
A chart, “Geo-Zip” report, matrix, graphic depiction, spreadsheet or other visual display that reflects (1) the names and addresses of medical providers in the Community that have performed the Relevant CPT Code Procedures, during the Relevant Period, and who have billed Defendant for those procedures; (2) the amounts that other medical providers have charged for performing the Relevant CPT Code Procedures, during the Relevant Period; (3) the amounts that Defendant has allowed as reasonable, approved or authorized charges for medical providers in the Community that have billed Defendant for the Relevant CPT Code Procedures, for procedures performed during the Relevant Period; and (4) the amounts that Defendant has paid medical providers in the Community that have billed Defendant for the Relevant CPT Code Procedures, for procedures performed during the Relevant Period.
A copy of any and all executed agreements/contracts between Defendant and/or any other third party auditing vendor if utilized to adjust, process or facilitate the adjusting or processing of the Claim and in effect during the Relevant Period.
Any and all documents that evidence, demonstrate or show that Defendant “auto-processed” the Claim or that Defendant did not “auto-process” the Claim.
Copies of each and every document that supports, proves or tends to support any of the affirmative defenses Defendant asserts in the present litigation.
