27 Fla. L. Weekly Supp. 755a
Online Reference: FLWSUPP 2708ADAVInsurance — Personal injury protection — Coverage — Medical expenses — Multiple Procedure Payment Reduction — PIP statute establishes that allowable amount under 2007 Medicare fee schedule must be used to calculate reimbursement when it is higher than allowable amount under applicable year’s Medicare fee schedule, but statute also permits that allowable amount to then be reduced by application of Medicare’s MPPR
FOUNTAINS THERAPY CENTER, INC., a/a/o Ava Davis, Plaintiff(s) / Petitioner(s), v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant(s) / Respondent(s). County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE17000020, Division 54. October 7, 2019. Florence Barner, Judge. Counsel: Tara L. Kopp, Schuler Halvorson, Weisser, Zoeller and Overbeck, P.A., West Palm Beach, for Plaintiff. Gregory J. Willis and Viraj A. Mehta, Cole, Scott & Kissane, P.A., Plantation, for Defendant.
SUMMARY JUDGMENTORDER GRANTING DEFENDANT’S MOTIONFOR FINAL SUMMARY JUDGMENT AND DENYINGPLAINTIFF’S MOTION FOR SUMMARY JUDGMENT
THIS CAUSE having come before the Court on September 24, 2019 on Plaintiff’s and Defendant’s Cross Motions for Final Summary Judgment regarding the application of MPPR to the Plaintiff’s PIP charges and the Court, having heard argument of counsel, having reviewed the file and the Court being otherwise fully advised in the premises, ORDERS AND ADJUDGES, that for the reasons set forth below, Defendant’s Motion for Final Summary Judgment is GRANTED and Plaintiff’s Motion for Summary Judgment is DENIED and Final Judgment is entered for the Defendant:
FINDINGS OF FACT
1. Plaintiff filed a claim for Personal Injury Protection (“PIP”) and Medical Payment benefits arising from an automobile accident, which occurred on or about May 21, 2013.
2. The Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY (hereinafter “State Farm”), issued a policy of automobile insurance (“Policy”) to its insured, AVA DAVIS, which included among other coverages, $10,000.00 in PIP and $5,000.00 in Medical Payment coverage.
3. The Policy was in effect on the date of accident, May 21, 2013.
4. Because of the automobile accident, Ava Davis, sustained injuries and thereafter received a cervical MRI (CPT code 72141) and a thoracic MRI (CPT code 72146) at the Plaintiff’s facility on June 20, 2013.
5. Plaintiff billed STATE FARM a total amount of $2,232.00 for the two MRI’s rendered to Ava Davis. Defendant allowed $630.11 for CPT 72141 and $1,116.00 for CPT 72146. Defendant thereafter issued payment for $1,746.11 to the Plaintiff. In determining the proper allowed amount, Defendant first compared the applicable 2013 Medicare Part B physicians’ fee schedule to the 2007 Medicare Part B limiting charge, which increased the amount being allowed since the allowed amount under the 2007 Medicare Part B schedule was greater. State Farm further increased the allowed amount by utilizing the 2007 Medicare Part B “limiting charge” rather than using the 2007 Medicare “physicians’ fee schedule” amount. Next, State Farm reduced the allowed amount for Plaintiff’s bills based upon Medicare’s MPPR being applied to the 2007 Limiting Charge of Medicare Part B payment amount. MPPR (Multiple Procedure Payment Reduction) is a Medicare pricing guide applied to certain designated procedures when multiple procedures are performed on the same day in the same facility.
6. For purposes of this case, Plaintiff is not disputing Defendant’s ability to utilize the schedule of maximum charges set forth under Fla. Stat. 627.736(5) (a). Plaintiff also does not contest Defendant’s ability to be permitted to utilize MPPR in general as a Medicare payment methodology as that term is used in Fla. Stat. 627.736(5)3. However, Plaintiff does contest whether State Farm may reimburse for the services at a rate less than the allowed amount under the 2007 Medicare Part B schedule. This contention is the remaining issue in the case.
CONCLUSIONS OF LAW
1. Here, there is no dispute that the policy properly incorporates the Medicare fee schedule and payment methodologies. Likewise, in the absence of an inter-district conflict, the Second District Court of Appeal’s decision in State Farm Mutual Automobile Insurance Company v. MRI Associates of Tampa, Inc. dba Park Place MRI (“Park Place MRI”), is binding on all Florida trial courts. See Pardo v. State, 596 So. 2d 665 (Fla. 1992). Park Place MRI has found that: “[b]ecause the State Farm policy includes mandatory language expressly limiting reimbursement for reasonable medical expenses to the schedule of maximum charges set forth in section 627.736(5) (a) (1) (a)-(f), we conclude that it is sufficient to place insureds and service providers on notice as required by section 627.736(5)(a)(5) [emphasis added]” State Farm Mut. Auto. Ins. Co. v. MRI Associates of Tampa, Inc. dba Park Place MRI, 252 So.3d 773, 778 (Fla. 2d DCA 2018) [43 Fla. L. Weekly D1149a].
2. As to the issue of the application of the MPPR limitation to the 2007 Medicare fee schedule, this Court has previously reasoned in Total MD (a/a/o MICHELLE HOLLOWAY) v. Progressive American Insurance Company, Brwd. Cty. Case No. COCE16-19450 (April 8, 2019) that if the service is not covered under Medicare, then the Defendant cannot apply the additional MPPR reduction as a Medicare limitation. However, if Medicare covers the service or procedure and the policy properly elects the Medicare fee schedule including its coding and payment methodologies and limitations, then the Defendant may apply the MPPR reduction accordingly. The Honorable Judge Nina DiPietro faced a similar issue and reasoned that “as written, subparagraph (2) of Fla. Stat. §627.736(5) (a) does not modify or limit subsection (3), or vice versa, but instead they each separately address subsection (1). Subparagraph (2) clarifies what fee schedule should be used when determining the allowable amount referenced in subparagraph (1). Subparagraph (3) makes it clear that insurers can use Medicare coding policies and CMS payment methodologies when determining the reimbursement amount. Had the legislature intended for insurers to only be permitted to use Medicare coding policies and CMS payment methodologies if the reimbursement amount equaled more than the allowable amount in Medicare Part B’s 2007 fee schedule [i.e. subsection (2) created a prohibition on subsection (3)], the legislature could have drafted a provision that specifically stated so.” Plantation Open MRI, LLC v. State Farm Mutual Automobile Insurance Company, Brwd. Cty. Case No. COCE 14-011350 &14-011351 (July 27, 2017) [25 Fla. L. Weekly Supp. 831a]. Judge DiPietro ultimately held that “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.” Id.
3. Based on the foregoing findings, it is ORDERED AND ADJUDGED that final judgment be and the same is hereby entered in favor of Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY and against the Plaintiff FOUNTAINS THERAPY CENTER, INC. The court reserves jurisdiction to determine whether reasonable fees and costs should be awarded, and the amount thereof, upon the filing of a timely motion.
