25 Fla. L. Weekly Supp. 364b
Online Reference: FLWSUPP 2504VDIAInsurance — Personal injury protection — Coverage — Medical expenses — Medicaid Multiple Procedure Payment Rule does not limit use or duration of services and does not prevent insured from accessing any procedure — Accordingly, insurer’s application of MPPR is permitted under no-fault statute — Insurer properly applied MPPR for the year in which services were rendered — Section 627.736(5)(a)(3) has no language requiring “substitution” of 2007 Medicare Coding policies or payment methodologies
HEALTH DIAGNOSTICS OF ORLANDO, LLC, d/b/a STAND UP MRI OF ORLANDO, a/a/o Vita Diaz, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County, Civil Division. Case No. 2015-SC-014184-O, Division 73. April 28, 2017. Jeanette Bigney, Judge. Counsel: Robert Horst, Orlando, for Plaintiff. Robert H. Oxendine, Oxendine and Oxendine, P.A., Tampa, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FORSUMMARY JUDGMENT AND DENYINGPLAINTIFF’S MOTION FOR SUMMARY JUDGMENT
THIS CAUSE having come before the Court on October 31, 2016, pursuant to Defendant’s Motion for Summary Judgment and Plaintiff’s Motion for Summary Judgment, and the Court having reviewed the file, pleadings and written submissions, heard the arguments of counsel, and being otherwise fully advised in this matter, does hereby make the following findings of fact and conclusions of law:
1. On June 28, 2013, Vita Diaz was involved in an automobile accident in which she allegedly sustained injuries. As a result of those alleged injuries Ms. Diaz was referred for MRI studies of the cervical and lumbar spine by her treating physician, Dr. Carlisi, D.C. Those MRI tests were performed on August 15, 2013 at Plaintiff’s diagnostic facility. At thetime of the subject accident, Ms. Diaz was covered under an insurance policy with Defendant providing no-fault benefits. Plaintiff is an assignee of that policy.
2. The two MRIs performed by Plaintiff were billed under CPT codes 72141 and 72148. The tests were performed on the insured patient on the same day during the same visit. In processing the Plaintiff’s claim for PIP benefits, the Defendant reduced the Plaintiff’s charges based on the Medicare Multiple Procedure Payment Rule (“MPPR”). According to Defendant, its payment for both CPT codes 72141 and 72148 was based upon 200% of the 2007 version of Medicare’s limiting charge fee schedule, and then the Defendant applied the 2013 version of MPPR to that charge resulting in a 25% reduction to the amount of the professional component (PC) for CPT code 72148 and 50% reduction to the technical component (TC) for CPT code 72141.
3. Each party filed a Motion for Final Summary Judgment in this case. The Defendant’s Motion for Summary Judgment asserted that it was authorized to apply the 2013 version of MPPR to the Plaintiff’s bills for services rendered to the same patient on the same date of service. In contrast, Plaintiff, in support of its Motion for Summary Judgment, argues that Defendant could not rely on MPPR and/or that Defendant misapplied the 2013 MPPR resulting in an unlawful underpayment.
4. For purposes of this case, Plaintiff does not challenge Defendant’s ability to rely on the fee schedule methodology set for in Section 627.736(5)(a)1-5, Florida Statutes (2013), and is willing to accept payment of the fee schedule method amount.
CONCLUSIONS OF LAW
5. It is axiomatic that all parts of a statute must be read together in order to achieve a consistent whole. Forsythe v. Longboat Key Beach Erosion Control Dist., 604 So.2d 452, 455 (Fla. 1992). “Where possible, courts must give full effect to all statutory provisions and construe related statutory provisions in harmony with one another.” Id.
6. Florida’s No-Fault Law, codified in Fla. Statute Section 627.736 has been subject to several versions and amendments. Under prior versions, Florida Courts did not permit the use of Medicare payment methodologies and/or coding policies in calculating reimbursement amounts. See, e.g., SOCC, P.L. v. State Farm Mutual Automobile Insurance Company, 95 So.3d 903, 908 (Fla. 5th DCA 2012) [37 Fla. L. Weekly D1663a]. By contrast, this claim arises under the 2012 version of the No-Fault Statute which explicitly permits an insurer to consider Medicare coding policies and payment methodologies “if the coding policy or payment methodology does not constitute a utilization limit.”
7. The Court concludes that MPPR does not limit the use or duration of services and does not prevent the insured from accessing any procedure. Accordingly, the Defendant’s application of the MPPR does not constitute a “utilization limit” and is permitted under the no-fault statute.
8. The Plaintiff further contends that Defendant misapplied MPPR by superimposing the more recent 2013 Medicare MPPR upon the 2007 Medicare Fee Schedule (which was used to calculate the base reimbursement amount) and that the use of the 2013 MPPR rate thus violated Florida Statute Section 627.736(5)(a)(2), which provides that the reimbursement amount may not be less than the “allowable amount under the applicable schedule of Medicare Part B for 2007.”
9. The Court disagrees with this argument and finds that Defendant properly applied the 2013 MPPR since Florida Statute Section 627.736(5)(a)(3), unlike Section (5)(a)(2), has no language requiring the “substitution” of 2007 Medicare Coding policies or payment methodologies; therefore, Defendant properly applied the MPPR rule for the year in which the services were rendered. Subparagraphs (2) and (3) of Section 627.736(5)(a) do not modify each other, but instead each separately modify subparagraph (1) of Section 627.736 (5)(a).
BASED ON THE FOREGOING, it is hereby:
ORDERED AND ADJUDGED that Defendant’s Motion for Summary Judgment is GRANTED. Plaintiff’s Motion for Summary Judgment is DENIED.
This Court reserves jurisdiction to consider any applicable claims for taxable costs.
