26 Fla. L. Weekly Supp. 48b
Online Reference: FLWSUPP 2601INJUInsurance — Personal injury protection — Coverage — Medical expenses — Statutory fee schedules — Policy properly incorporated ability to limit payment pursuant to section 627.736(5)(a)(1) — Statute allows insurers to use Medicare coding policies and payment methodologies of federal Centers for Medicare and Medicaid Services, including applicable modifiers, to determine appropriate reimbursement if coding policy or payment methodology does not constitute utilization limit — Policy provided adequate notice that defendant would be using same — Limits for physician assistant services constitute a Medicare coding policy or payment methodology of federal Centers for Medicare and Medicaid Services
INJURYONE INC., Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE16-009462 (49). September 29, 2017. Nina W. Di Pietro, Judge.
ORDER GRANTING DEFENDANT’S MOTIONFOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE having come on to be heard on September 20, 2017, regarding Defendant’s Motion for Partial Summary Judgment (hereinafter “Defendant’s Motion”), and the Court having reviewed Defendant’s Motion, the entire Court file, 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:
Defendant’s Motion requests that the Court make several rulings. First, Defendant requests that the Court find that its policy of insurance, State Farm Policy Form 9810A, properly incorporates the ability to limit payment pursuant to Florida Statute §627.736(5)(a)(1). As was stated on the record at the hearing on Defendant’s Motion, the Court grants this request for the reasons set forth in this Court’s May 26, 2017 written opinion in the matter of Precision Diagnostics of Lake Worth v. State Farm Mutual Automobile Insurance Company, COCE 16-005859 (49) [25 Fla. L. Weekly Supp. 295a].
Defendant’s Motion next requests that the Court find that Defendant’s policy of insurance permits for Defendant to use Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services. As was stated on the record at the hearing on Defendant’s Motion, the Court grants this request based upon the following: 1. The Court’s finding that Defendant’s policy of insurance properly incorporates the ability to limit payment pursuant to Florida Statute §627.736(5)(a)(1); 2. Florida Statute §627.736(5)(a)(3) allows for insurers to use the Medicare coding policies and payment methodologies of the federal Centers for Medicare and Medicaid Services, including applicable modifiers, to determine the appropriate amount of reimbursement for medical services, supplies, or care if the coding policy or payment methodology does not constitute a utilization limit; and 3. Defendant’s policy of insurance provides adequate notice that Defendant will be using same.
Defendant’s Motion finally requests that the Court find that the following provision, found in the Medicare Claims Processing Manual Chapter 12, Section 110, pertaining to Physician Assistant (PA) Services Payment Methodology, constitutes a Medicare coding policy or payment methodology of the federal Centers for Medicare and Medicaid Services: Physician assistant services are paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule. Although for this case only, Plaintiff stipulates that this provision does in fact constitute a Medicare coding policy or payment methodology of the federal Centers for Medicare and Medicaid Services, the Court independently finds the same.
