25 Fla. L. Weekly Supp. 553a
Online Reference: FLWSUPP 2506SGORInsurance — Personal injury protection — Coverage — Medical expenses — Multiple Procedure Payment Reduction — Clear and unambiguous election by insurer — PIP policy containing general references to Medicare coding policies and procedures does not clearly elect use of Medicare MPPR rule to reduce payment below permissive statutory fee schedule
PAN AM DIAGNOSTIC SERVICES, INC, d/b/a Wide Open MRI (a/a/o Shaun Gordon) Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami Dade County. Case No. 13-21679 SP 23 (2). November 29, 2016. Caryn Schwartz, Judge.
ORDER DENYING DEFENDANT’S MOTION FORSUMMARY JUDGMENT AND GRANTINGPLAINTIFF’S MOTION FOR SUMMARY JUDGMENTAS TO REIMBURSEMENT METHODOLOGY
THIS CAUSE came before the Court on November 15, 2016, on: (1) Plaintiff’s Second Updated Cross-Motion for Final Summary Judgment, and Defendant’s Amended Motion for Partial Summary Judgment. The Court, having considered the motions, the argument of counsel, and the record, and being otherwise advised in the premises, DENIES Defendant’s Motion and GRANTS the Plaintiff’s Motion in part, as to reimbursement methodology:
Facts of the Case
This is a personal injury protection (“PIP”) case, where the Plaintiff seeks damages for unpaid benefits. Plaintiff performed two MRIs, CPT code 72141, cervical, and CPT code 72148, lumbar, upon the assignor in this case, Shaun Gordon, and timely sent Defendant a bill for same. The Defendant admits that the assignor was covered at the relevant time under a policy it issued, which was then in full force and effect. The Defendant approved the claim in the amounts of $672.80 for CPT code 72141 and $1,206.66 for CPT code 72148, and paid Plaintiff 80% of that. The Defendant filed State Farm’s 9810A policy form, which the parties agree is the operative policy in this case. The Plaintiff filed suit for $266.00; the difference between 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule amount for the services at issue, and the amount paid by the Defendant. The Parties agree that the total amount claimed by the Plaintiff, $1,773.04, is 80% of 200% of the 2007 Medicare Part B Physician Fee Schedule for the services at issue.
The Parties’ Arguments
The Plaintiff argues that Defendant’s 9810A policy form, at p. 16, clearly states that Defendant will pay 80% of “the allowable amount under (1) The participating physicians fee schedule of Medicare Part B except as provided in sub-sub-paragraphs (II) and (III).” The exceptions provided in sub-sub-paragraphs (II) and (III) do not apply. The policy further states: “For purposes of the above, the applicable fee schedule or payment limitation in effect on March 1 of the year in which the services are rendered. . .except that it will not be less than the allowable amount under the applicable schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.”
The Defendant argues that there is also language on p. 16 of said policy stating: “We will limit payment of Medical Expenses described in the Insuring Agreement of this policy’s No-Fault Coverage to 80% of a properly billed and documented reasonable charge, but in no event will we pay more than 80% of the following No-Fault Act “schedule of maximum charges” including the use of Medicare coding policies and payment methodologies of the Federal Centers for Medicare and Medicaid Services, including applicable modifier;” and on page 5, which states: “Reasonable Charge, which includes reasonable expense, means an amount to be determined by us to be reasonable in accordance with the No-Fault Act, considering one or more of the following:. . .Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services, including applicable modifiers, if the coding policy or payment methodology does not constitute a utilization limit.” Defendant argues that that language permits it to limit PIP reimbursements below the allowable amount under the 2007 Medicare Part B physicians fee schedule, based on a Medicare rule that allows for reduced payments when multiple procedures are performed in single session (hereafter referred to as “MPPR”).Findings of law:
The construction of an insurance policy is a question of law. See Jones v. Utica Mut. Ins. Co., 463 So. 2d 1153, 1157 (Fla. 1985). Such contracts are interpreted in accordance with the plain language of the policy, and any ambiguities are liberally construed in favor of the insured and strictly against the insurer as the drafter of the policy. The Court previously ruled, in Interventional Spine Center LLC v. Progressive American Insurance Company, 23 FLWS 610a (County 11, 2015), that a policy that allows an insurer to choose the reimbursement method that it will utilize, is ambiguous as to reimbursement method. Although State Farm’s 9810A policy is different from the policy at issue in that case, the same underlying principle applies. The Defendant’s 9810A policy does state that Defendant will pay 80% of “the allowable amount under (1) The participating physicians fee schedule of Medicare Part B;” and does not clearly state that the Defendant will pay less than that based on the MPPR as opposed to any other Medicare sub-schedules, such as NCCI and OPPS. General references to Medicare coding policies and procedures on pp. 5 and 16 of policy do not clearly and unambiguously elect to pay pursuant to the MPPR. The Court therefore grants Plaintiff’s motion for summary judgment as to reimbursement methodology. The Court reserves ruling on the issue of the relatedness and necessity of the services at issue.
