25 Fla. L. Weekly Supp. 831a
Online Reference: FLWSUPP 2509PLANInsurance — Personal injury protection — Coverage — Medical expenses — Policy adequately put insureds on notice that, if applicable, insurer would use Medicare coding policies and payment methodologies, including applicable modifiers, to determine reimbursement for claims involving medical services, supplies, and/or care — Policy permitted insurer to reimburse provider below Medicare Part B fee schedule through application of Medicare’s Multiple Procedure Payment Reduction
PLANTATION OPEN MRI, LLC, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court in and for Broward County. Case Nos. COCE 14-011350 (54) and COCE 14-011351 (54). November 3, 2017. Nina W. Di Pietro, Judge. Counsel: Todd A. Landau, for Plaintiff. Omar A. Giraldo, for Defendant.
ORDER GRANTING DEFENDANT’S SECOND AMENDEDMOTIONS FOR FINAL SUMMARY JUDGMENT
THIS CAUSE having come before the Court on September 26, 2017 for a consolidated hearing of Defendant’s Second Amended Motions for Final Summary Judgment (hereinafter “Defendant’s Motions”) both filed on June 5, 2017 for cases COCE14-011350 and COCE14-011351, and the Court having reviewed Defendant’s Motions, the entire court files, and the relevant legal authorities; having heard argument; having made a thorough review of the matters filed of record; and having been sufficiently advised in the premises, the Court finds as follows:
The following material facts are undisputed: The patient in case COCE14-011350, Florana L’Homme, sustained injuries in an automobile accident on September 4, 2013; the patient in case COCE14-011351, Merlande Dennis, sustained injuries in an automobile accident on September 14, 2013; both of these patients were covered under separate policies of insurance (both Policy Form 9810A) issued by Defendant, State Farm Mutual Automobile Insurance Company (hereinafter “Defendant”); and Plantation Open MRI, LLC (hereinafter “Plaintiff”), as an assignee of the patients, submitted separate bills to Defendant for diagnostic services (CPT Codes 72141 and 72148) rendered to both patients on October 15, 2013. In processing Plaintiff’s aforementioned claims, Defendant issued payment to Plaintiff at an amount less than 200% of the 2007 Medicare Fee Schedule as Defendant first applied a fee schedule reduction (to the allowable amount under the 2007 Medicare Part B fee schedule) and then further reduced the allowable amount based on Medicare’s Multiple Procedure Payment Reduction (hereinafter “MPPR”).
The parties agree, for purposes of the legal issues discussed in Defendant’s Motions, that there are no disputed issues of material fact. Further, for these particular cases only, Plaintiff does not challenge Defendant’s ability to rely on the fee schedule methodology set forth in Sections 627.736(5)(a)(l-5), Florida Statutes (2013), and is willing to accept payment of the fee schedule method amount. Thus, the matter is ripe for summary judgment.
The parties previously came before the Court on June 13, 2017 for a hearing on Plaintiff’s Cross Motions for Summary Judgment. The legal issue presented at that time was whether Defendant used MPPR in compliance with the provisions in Fla. Stat. §627.736(5)(a). At the hearing, the Court made the initial ruling that Defendant’s Policy Form 9810A adequately put its insureds on notice that, if applicable, Defendant will use Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services (hereinafter “Medicare coding policies and CMS payment methodologies”), including applicable modifiers, to determine reimbursement for claims involving medical services, supplies, and/or care. In this Court’s July 11, 2017 Order Denying Plaintiff’s Cross Motions for Summary Judgment, the Court found that MPPR, a CMS payment methodology, does not constitute a utilization limit. The Court further found that while Fla. Stat. §627.736(5)(a)(2) establishes that the allowable amount in the 2007 Medicare Part B fee schedule must be used when it is higher than the applicable year’s Medicare Part B fee schedule’s allowable amount, Fla. Stat. §627.736(5)(a)(3) permits for that allowable amount to then be reduced by applicable and permissible Medicare coding policies and CMS payment methodologies when determining the amount of reimbursement for the claim.
Based upon the evidence of record in both cases in conjunction with the above described rulings, Defendant now seeks for the Court to enter Final Summary Judgments. At the hearing on Defendant’s Motions, Plaintiff argued that although the Court has ruled that Fla. Stat. §627.736(5)(a) permits for an insured to reimburse below the 2007 Medicare Part B fee schedule through the application of MPPR, Defendant’s policy language does not.
Defendant’s Policy Form 9810A, states the following:
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 modifiers. . .
f. For all other medical services, supplies, and care, 200 percent of the allowable amount under:
(I) The participating physicians fee schedule of Medicare Part B, except as provided in sub-sub-subparagraphs (II) and (III) [which are inapplicable in this case]. . .
For purposes of the above, the applicable fee schedule or payment limitation under Medicare is the fee schedule or payment limitation in effect on March 1 of the year in which the services, supplies, or care is rendered and for the area in which such services, supplies, or care is rendered, and the applicable fee schedule or payment limitation applies throughout the remainder of that year, notwithstanding any subsequent change made to the fee schedule or payment limitation, 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.
State Farm Policy Form 9810A, page 16.
The Court finds that Defendant’s policy language, although formatted differently, has the same effect as the language in Fla. Stat. §627.736(5)(a). Defendant’s policy states that it will not pay more than 80% of the schedule of maximum charges including the use of Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services. While Defendant’s policy contains a directive for which fee schedule must be used, the directive does not override Defendant’s ability to then reduce that fee schedule’s allowable amount through the use of Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services. Therefore, the Court finds that Defendant’s Policy Form 9810A permitted Defendant to reimburse Plaintiff below the 2007 Medicare Part B fee schedule through the application of MPPR.
ORDERED AND ADJUDGED that Defendant’s Second Amended Motions for Summary Judgment are Granted.
