25 Fla. L. Weekly Supp. 382c
Online Reference: FLWSUPP 2504HEREInsurance — Personal injury protection — Coverage — Medical expenses — Reasonable charges — Under PIP statute, if medical provider’s charge is reasonable, insurer must pay that amount even if its own amount of proposed reimbursement might also be deemed reasonable — Where provider’s charges fall clearly within range of MRI charges for non-hospital settings in South Florida, charges are reasonable
MILLENNIUM RADIOLOGY, LLC (a/a/o Yesenia Heredia), Plaintiff, v. UNITED AUTOMOBILE INSURANCE COMPANY, Defendant. County Court. 17th Judicial Circuit, in and for Broward County. Case No. 14-23844 COCE (53). March 30, 2017. Robert W. Lee, Judge. Counsel: Wajih A. Shirazi and Antonella Dos Santos, Dos Santos & Shirazi, L.L.C., Miami, for Plaintiff.
[Related Order at 25 Fla. L. Weekly Supp. 384a]
FINDINGS OF FACT AND CONCLUSIONS OF LAWUPON BENCH TRIAL
THIS CAUSE came before the Court on March 28, 2017 for trial, and the Court’s having received evidence; reviewed the relevant legal authorities; heard argument; made findings of credibility consistent with this judgment; and been sufficiently advised in the premises, the Court finds as follows:
Findings of Fact. This case proceeded to trial on the issue of the reasonableness of the Plaintiff’s charges for two MRIs performed in 2011 at its facility in Miami-Dade County: a cervical MRI (CPT code 72141) and a lumbar MRI (CPT code 72148). The Plaintiff billed $2,150.00 for each MRI, expecting to be paid 80% of that amount pursuant to the PIP statute, a total of $3,440.00. Instead, the insurer paid a total of $1,905.26. This amount was calculated at 80% of 200% of the Medicare fee schedules. The Defendant used the Medicare fee schedules although it had not selected the Medicare fee schedule methodology of payment in its policy. However, the Defendant argues that, considering all the factors set forth in the statute for determining the reasonableness of the charges, the Plaintiff’s MRI charges are nonetheless unreasonable. Notwithstanding this statement, the bulk of the Defendant’s argument at trial was not focused on the Plaintiff’s charges, but rather that its own reimbursement was reasonable.
The Plaintiff presented as its sole witness Roberta Kahana. She testified that she was involved in starting the company in 2007, and that she is the person primarily responsible for the overall running of the business, as well as setting the charges. She further testified that the charge for both MRIs was set at $2,150.00 at the time the business was opened, and the price has not increased since that time. Ms. Kahana set the prices by calling numerous area providers in 2007, and picking a fee that she believed was “in the middle” of what she gleaned from her survey.
The Plaintiff attempts to run its business with a more personal level of touch than the average diagnostic facility, focusing on minimizing the wait time of each patient and sitting with those through the procedure who might be nervous or claustrophobic. The Plaintiff also strives to provide a rapid turnaround time, using modern technology to transmit the MRI results to a professional who prepares the MRI report usually within 6 to 7 hours of the MRI. The business model focuses primarily on automobile accidents, with less than 7% of patients being referred from other sources.
Initially, the Plaintiff routinely received 80% of its billed amount for MRI services. The Plaintiff has also in the past received this amount from the Defendant, United Automobile. After the statute was amended, however, to further define how a “reasonable charge” should be determined, the Plaintiff began to receive approval of less than the full billed amount. In the instance of United Automobile, the choice to approve a less amount was due to the Defendant’s belief that it had properly exercised its right to charge 200% of the Medicare amount, when it had not in fact done so. Pursuant to the statute, however, the Defendant is entitled to challenge the reasonableness of the Plaintiff’s charges, even after it has made a payment on the bill relying on an incorrect methodology.
The Defendant presented as its sole witness Dr. Edward Dauer, a diagnostic radiologist who owns his own diagnostic testing facility in the Broward city of Lauderdale Lakes. He began working in this field in 1983. Unlike the Plaintiff in this case, at the time of the treatment in the instant case, Dr. Dauer’s facility received very few automobile accident patients (less than 1% of his cases), a paucity that continues to this day. In 2004, he set his rate for MRIs at $1,080.00 for CPT code 72141 and $1,160.00 for CPT code 72148. While he has not raised his rates since then, he acknowledged that facilities in Miami-Dade County charge up to 5% higher than Broward rates. This would adjust his rates to $1,134.00 for CPT code 72141 and $1,218.00 for CPT code 72148.
Dr. Dauer testified that he has “wide exposure” to the amount that South Florida providers charge, and he has reviewed “thousands” of medical bills for MRIs in the tri-county area. He acknowledges a “wide range of prices.” In a non-hospital setting, he sees charges in the range of $550.00 – $2,500.00, while in a hospital setting, he sees charges from $3,500 up to a high of $10,000.00. Importantly, Dr. Dauer stated that it is not his view that “anything” above 200% of Medicare is an unreasonable charge. Rather, he focused on the reasonableness of United Automobile’s reimbursement, which he opined was clearly a reasonable amount because he focuses on what is actually reimbursed by Medicare, managed care providers, and payors other than automobile insurance.
Dr. Dauer acknowledged that in a non-hospital setting, what is reimbursed for an MRI is generally a standard across-the-board lower amount, with the exception of PIP cases. He further stated that “PIP is the best payor.” He did not articulate any reason why he thought this was so.
Conclusions of Law. Under Florida law, a PIP insurer must pay a medical charge if that charge is “reasonable.” The sole issue in this case is whether the charges for the two MRIs are “reasonable. If [the court] finds the charge for [the] service reasonable, [the court] should award that amount as damages.” Fla. Std. Jury Instr. 413.4(a). In deciding whether the amount of a charge is reasonable, the court may consider evidence of:
(a) usual and customary charges and payments accepted by the provider involved in the dispute;
(b) reimbursement levels in the community;
(c) reimbursement levels in various federal and state medical fee schedules applicable to automobile coverages; and
(d) and any other information relevant to the reasonableness of the reimbursement for the service.
Fla. Stat. §627.736(5)(a)(1) (2010).
In this case, the Plaintiff set its charges at $2,150.00 in 2007. The Defendant’s own expert acknowledged a wide range of prices for MRIs in South Florida. In some settings, charges for MRIs can go as high as $10,000.00. In a non-hospital setting, such as in the Plaintiff’s case, they are not as high, but can go as high as $2,500.00. He further acknowledged that charges in automobile accidents are higher than other types of cases. While he testified that he “routinely” received less than what he actually billed, he has not adjusted his own actual “charges” downward to take into consideration the reality of payments he accepts.
As noted, both Dr. Dauer and defense counsel focused much of their argument on the insurance company’s reimbursement amount. Indeed, defense counsel’s closing argument was almost solely based on its position that the Defendant paid a reasonable amount. This argument misses the point. While indeed the Defendant’s reimbursement might be deemed a reasonable amount, the Defendant must pay the Plaintiff’s charge is the Plaintiff’s charge is reasonable. In other words, it is possible in this case that both amounts might be reasonable. But, the way the statute is phrased, if the Plaintiff’s charge is reasonable, the insurer must pay that amount, even if its own amount might be deemed reasonable. See State Farm Mutual Automobile Ins. Co. v. New Smyrna Imaging, LLC, 22 Fla. L. Weekly Supp. 508a, 509 n.1 (7th Cir. App. 2014).
Although the Plaintiff’s charges fall clearly within the range of MRI charges that Dr. Dauer has seen for non-hospital settings in South Florida, and although the Plaintiff’s charges do not encroach into the area he has seen for hospital facility charges, Dr. Dauer believes that the Plaintiff’s charges are unreasonable. Based on a preponderance of the credible evidence presented in this particular case, as well as the law of the State of Florida, the Court rejects Dr. Dauer’s conclusion and finds the Plaintiff’s charges for the two MRIs in 2011 to be reasonable. Accordingly, it is hereby
ORDERED that the Plaintiff shall submit to the Court a proposed final judgment conforming to these Findings.
