25 Fla. L. Weekly Supp. 92a
Online Reference: FLWSUPP 2501BORGInsurance — Coverage — Medical expenses — Denial — False and misleading statements on billing statements
NEW HEALTH REHABILITATION CENTER, CORP a/a/o Pablo Borghi, Plaintiff, v. STATE FARM FIRE AND CASUALTY COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County. Case No. 2012 5613 CC 25 (01). December 31, 2016. Final Judgment filed January 18, 2017. Laura A. Stutzin, Judge. Counsel: Julie Barranco, The Law Offices of Gonzalez, Miami, for Plaintiff New Health Rehabilitation Center, Corp. Jessica Z. Martin, ROIG Lawyers, Deerfield Beach, for Defendant.
ORDER ON DEFENDANT’S MOTION FORFINAL SUMMARY JUDGMENT
This matter having come before the Court on Defendant’s Motion for Final Summary Judgment regarding Plaintiff’s submission of False and Misleading Statements in violation of Florida Statute § 627.726(5)(b)l.c. In support of its Motion, Defendant filed the Affidavit of its Claims Representative, deposition testimony of Plaintiff’s Corporate Representative/Person With Most Knowledge of Billing taken in several cases, and deposition testimony of Dr. Edgardo Ariza, MD. In opposition to Defendant’s Motion for Summary Judgment, New Health filed two affidavits of Orelbis Rodriguez, Owner of Plaintiff’s facility.
On December 21, 2016 this Court held a hearing where it received evidence and argument from both Defendant and Plaintiff. The Court has further reviewed the court file, analyzed the arguments, and weighed the evidence reviewed which serves as the basis of this order.UNDISPUTED FACTS
Plaintiff, New Health Rehabilitation Center (“New Health” or “Plaintiff”), brought the instant breach of contract action for Personal Injury Protection (“PIP”) benefits for medical services purportedly rendered to the insured Pablo Borghi following a motor vehicle accident. Amongst other charges, Plaintiff billed State Farm Fire and Casualty Company (“State Farm” or “Defendant”) for three (3) units of CPT code 97124 (massage therapy) and three (3) units of 97110 (therapeutic exercises) on fifteen separate dates of service. The medical records indicated that only two (2) units of massage therapy and two (2) units of therapeutic exercises were actually performed on the dates specified. Additionally, the Plaintiff billed for x-ray services utilizing CPT codes 72040, 72070, 72100, 73030 and 73100. The x-ray codes billed represent multiple views were performed. The medical reports indicated only one view was taken to the affected regions. During the pendency of litigation, the Plaintiff filed a notice of withdrawal of the additional units and all x-rays services Defendant alleged constituted a false and misleading statement. The affidavits of Mr. Rodriguez stated that the additional units and x-ray services were billed in error.STANDARD
It is a settled principle of law that a movant for summary judgment has the initial burden of demonstrating the nonexistence of a genuine issue of material fact. Ramos v. Wright Superior Inc., 610 So.2d 46 (Fla. 3rd DCA 1992). Only when that burden is satisfied does it shift to the opposing party to come forward with evidence to the contrary.
Section 627.736(5)(b)1.c. reads as follows:
(b)1. An insurer or insured is not required to pay a claim or charges:
. . .
c. To any person who knowingly submits a false or misleading statement relating to the claim or charges.
The word “knowingly” is subsequently defined in section 627.732(10):
“Knowingly” means that a person, with respect to information, has actual knowledge of the information; acts in deliberate ignorance of the truth or falsity of the information; or acts in reckless disregard of the information, and proof of specific intent to defraud is not required.
Person is defined in section 1.01(3):
“The word “person” includes individuals, children, firms, associations, joint adventures, partnerships, estates, trusts, business trusts, syndicates, fiduciaries, corporations, and all other groups or combinations.
ANALYSIS
In this instance, the plain language of section (5)(b)1.c. supports invalidation of the Plaintiff’s claim. The unrebutted facts of evidence show that the Plaintiff billed for medical services it did not provide. Moreover, the affidavit of Mr. Rodriguez supports that the charges were not performed as billed. The law regarding a provider’s submission of false and misleading statements is clear — that the submission of false statements render the entire claim non-compensable. Chiropractic One, Inc. v. State Farm, 92 So. 3d 871, 874 (5th DCA 2012) [37 Fla. L. Weekly D1565a] (affirming the lower court’s order granting insurer’s Motion for Final Summary Judgment where a medical provider made false and misleading statement in claims for PIP benefits, the insurer did not owe the provider PIP or Medpay benefits for any of the claims, and the insured did not owe the provider compensation for services pursuant to 627.736(5)(b)1.c.); see also United Automobile Ins. Co. v. East Coast, 19 Fla. L. Weekly Supp. 536b (11th Jud. App. 2012)(citing Chiropractic One and likewise finding that submission of false statements render the entire claim non-compensable).CONCLUSION
For the reasons set forth herein, the Court finds that there is no genuine issue of material fact regarding Plaintiff’s submission of false and misleading statements relating to billing of CPT codes 97124 and 97110 on fifteen1 dates of service and the billing of x-rays. Accordingly, it is ORDERED and ADJUDGED that Defendant’s Motion for Final Summary Judgment is hereby GRANTED. Plaintiff shall take nothing by this action and Defendant shall go hence forth without day. The Court hereby reserves jurisdiction to award reasonable attorney’s fees and costs if appropriate in favor of Defendant, State Farm Fire and Casualty Company as the prevailing party.
__________________
1Although there may be a genuine issue of fact as to Plaintiff’s billing of 97124 on two dates of service, it is irrelevant based on the other findings which bars the Plaintiff’s claim in its entirety.
__________________FINAL JUDGMENT
THIS CAUSE having come before the Court on Defendant’s Motion for Final Summary Judgment regarding Plaintiff’s submission of False and Misleading Statements and the Court having heard argument of counsel, and being otherwise advised in the Premises, it is hereupon,
ORDERED AND ADJUDGED as follows:
1. The Court, having granted Defendant’s Motion for Final Summary Judgment regarding Plaintiff’s Submission of False and Misleading Statements to Defendant on December 21, 2016, hereby enters final judgment in favor of Defendant State Farm Fire and Casualty Company.
2. Plaintiff shall take nothing by this action and Defendant shall go hence forth without day.
3. The Court reserves jurisdiction to determine attorney’s fees and costs.
