27 Fla. L. Weekly Supp. 312a
Online Reference: FLWSUPP 2703MRHInsurance — Health maintenance organizations — Out-of-network or non-participating provider rate — Inpatient emergency services provider — Reduction of claim to “allowed amount” — Because there was no contractual relationship between provider and HMO, rate of reimbursement was to be determined by section 641.513(5), which provides that reimbursement rate is lesser of provider’s charges, the usual and customary provider charges in the community, or a charge mutually agreed upon by HMO and provider within 60 days of submittal of claim — Because HMO failed to prove that “allowed amount” reduction of claim was agreed to by parties or the usual and customary charge in community, HMO was required to reimburse full amount of medical provider’s charge — HMO is also required to pay interest on overdue claim — Provider entitled to attorney’s fees and costs pursuant to section 641.28
PREMIER INPATIENT PARTNERS, LLC (M.R.H.), Plaintiff, v. FREEDOM HEALTH, INC., Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 18-CC-019835. November 1, 2018. Alissa McKee Ellison, Judge. Counsel: Daniel B. Smith, Morgan & Morgan, West Tampa, for Plaintiff. Bijal Patel, Tampa, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FORSUMMARY DISPOSITION: ORDER GRANTING PLAINTIFFENTITLEMENT TO ATTORNEY’S FEES AND COSTS
THIS CAUSE came before the Court on Plaintiff’s Motion for Entry of Summary Disposition and Entitlement to Attorney’s Fees, on October 30, 2018. Having considered the record, heard argument from counsel, and reviewed the evidence presented, the Court finds as follows:
Factual Background
Premier Inpatient Partners, LLC, (“Plaintiff”) is a hospital based health care provider of inpatient emergency services. On May 6-9, 2017, Plaintiff provided emergency healthcare services to patient R.T., who was insured by the defendant health maintenance organization (“HMO”) Freedom Health, Inc. (“Defendant”). Plaintiff electronically submitted a claim in the amount of $1058.00 to Defendant on May 26, 2017. Defendant unilaterally reduced Premier’s claim to $293.50 pursuant to its “allowed amount” and rendered partial payment on June 27, 2017. Plaintiff does not have a contract with Defendant and is therefore considered an out-of-network or non-participating medical provider. Because there is no contractual relationship between Plaintiff and Defendant, the rate of reimbursement with respect to the two parties is determined by section 641.513, Florida Statutes. Section 651.513(5) provides that Plaintiff’s claim reimbursement rate is the lesser or:
(a) provider’s charges;
(b) usual and customary provider charges in the community where the services were provided; or
(c) the charge mutually agreed by the health maintenance organization and the provider within 60 days of the submittal of the claim.
(2017).Motion for Summary Disposition
Plaintiff claimed Defendant reduced the subject claim below the minimum standards set forth by section 641.513(5), and initiated litigation against the Defendant for breaching the statutory requirements. Defendant failed to provide evidence that their “allowed amount” reduction was mutually agreed to by the parties or the usual and customary provider charge in the community where services were rendered. Without record evidence of the usual and customary charges, Plaintiff’s billed charges of $1058.00 are the appropriate reimbursement amount pursuant to section 641.513(5)(a).
Defendant’s untimely payment of Premier’s claim is also subject to statutory interest pursuant to section 641.3155, Florida Statutes (“Prompt Pay Statute”). Section 641.3155 provides that a provider’s electronically submitted claim must be paid, denied or contested within 20 days after receipt. § 641.3155(2)(b). In addition, all overdue claims bears simple interest rate of 12% from the time the claim should have been paid, denied or contested. § 641.3155(6). Here, Defendant received the claim on May 26, 2017, and did not render partial payment until June 27, 2017. Therefore, Plaintiff’s claim should have been paid with 12% interest from the time the claim should have been paid.
Entitlement to Attorney’s Fees and Costs
Plaintiff moved for attorney’s fees pursuant to section 641.28, Florida Statutes, which provides:
In any civil action brought to enforce the terms and conditions of a health maintenance organization contract, the prevailing party is entitled to recover reasonable attorney’s fees and court costs.
Plaintiff is the prevailing party as the provider enforced the terms and conditions of section 641.513(5), which becomes part of the subject HMO contract through the principle of statutory incorporation and the minimum contractual requirements of section 641.3105, Florida Statutes. As a result, Plaintiff is entitled to attorney’s fees and costs pursuant to section 641.28.
Accordingly, it is
ORDERED AND ADJUDGED that Plaintiff’s Motion for Summary Disposition is hereby GRANTED.
IT IS FURTHER ORDERED AND ADJUDGED that Plaintiff’s Motion for Attorney’s Fees pursuant to section 641.28 is hereby GRANTED. The Defendant is ordered to pay $764.50 along with 12% interest from June 16, 2017. The Defendant shall pay judgment within twenty (20) days from the date on this order. The Court reserves jurisdiction as to the determination of a reasonable amount of attorney fees, costs and expert fees upon motion and hearing.
