27 Fla. L. Weekly Supp. 416a
Online Reference: FLWSUPP 2704VOLTInsurance — Personal injury protection — Coverage — Medical expenses — Chiropractic services — Multiple procedure payment reduction — Chiropractic provider’s challenge to insurer’s use of MPPR to reduce amount it reimbursed provider below 200% of allowable amount under physicians fee schedule of Medicare Part B — Where insurer’s only basis for using MPPR is that it is a Medicare payment methodology, insurer was required to apply the payment method in the same manner as Medicare — Since the MPPR only applies to services for which Medicare does not reimburse chiropractors, the MPPR cannot apply to chiropractors — In other words, a reduction in reimbursement cannot be applied when no reimbursement is permitted for that service
SUNSHINE CHIROPRACTIC AND MEDICAL CENTER INC a/a/o Christopher Voltaire, Plaintiff(s)/Petitioner(s), v. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant(s)/Respondent(s). County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE17016778, Division 55. May 17, 2019. Daniel Kanner, Judge. Counsel: Erik Abrams, Landau & Associates, P.A., Sunrise, for Plaintiff. Erin G. Whitebook, Progressive PIP House Counsel, Fort Lauderdale, for Defendant.
ORDER DENYING DEFENDANT’S MOTIONFOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court on Defendant’s Motion for Final Summary Judgment, and the Court, having reviewed the motion and evidence; having reviewed the court file; the legal authorities supplied by the parties; and having heard extensive argument of counsel; and being otherwise sufficiently advised in the premises, it is hereby:
ORDERED AND ADJUDGED that Defendant’s Motion for Final Summary Judgment is DENIED for the following reasons:
In this case for personal injury protection (PIP) benefits, Plaintiff — a chiropractic facility — challenges Defendant’s use of the Multiple Procedure Payment Reduction (MPPR) to reduce the amount it reimbursed Plaintiff below 200% of the allowable amount under the participating physicians’ fee schedule of Medicare Part B.
For purposes of this case, Plaintiff did not contest Defendant’s election of the permissive fee schedule payment methodology set forth in Fla. Stat. § 627.736(5)(a)1.f. or Defendant’s use of various Medicare payment methodologies and coding policies as referenced in its insurance policy and Fla. Stat. § 627.736(5)(a)3. Accordingly, in this case, the Court finds that the MPPR is a Medicare payment methodology.
Progressive’s only basis for using the MPPR is that it is a Medicare payment methodology. Since Progressive purported to use a Medicare payment methodology, it must apply the payment method in the same manner as Medicare (otherwise it would not be a “Medicare payment methodology”).
Medicare does not apply the MPPR to chiropractors for two reasons: (a) Medicare uses the MPPR to reduce the amount it reimburses to only a select group of therapy service providers that expressly excludes chiropractors; and (b) coverage for chiropractic services under Medicare is limited to only chiropractic manipulation treatment. 78 F.R. 237, pp. 74428-29. Specifically, Medicare makes payment for only three codes listed in the chiropractic section of the CPT Manual: 98940 (Chiropractic manipulation treatment (CMT) spinal, 1-2 regions); 98941 (CMT spinal., 3-4 regions); and 98942 (CMT spinal, 5 regions). Id.
Since the MPPR only applies to services for which Medicare does not reimburse chiropractors, the MPPR cannot apply to chiropractors. In other words, a reduction in reimbursement cannot be applied when no reimbursement is permitted for that service.
The Medicare Claims Processing Manual provides that the therapy services to which the MPPR applies include only physical therapy, occupational therapy and speech-language pathology services, and “therapist” means only a physical therapist, occupational therapist or speech-language pathologist. The Centers for Medicare and Medicaid Services (CMS) also specifies that the MPPR may be applied only when therapists and certain physicians provide therapy services. See CMS Manual System Transmittal 88: Pub 100-02 Medicare Benefit Policy, May 7, 2008. The term “physician” with respect to outpatient rehabilitation therapy services means doctors of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only). Id. Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy
plans of care. Id. (Emph. added).
In addition to the foregoing, this Court agrees with and incorporates herein the sound analysis in Care Medical Centers, Inc. (a/a/o Ashley J. Linton) v. Progressive American Ins. Co. [26 Fla. L. Weekly Supp. 901a], Case No. COCE 18004563 (53), Order Granting Plaintiff’s Motion for Summary Judgment, Denying Defendant’s Motion for Summary Disposition/Judgment and Certification to the Fourth District Court of Appeal as a Question Affecting the Uniform Administration of Justice (Broward Cty. Ct., Nov. 28, 2018)(Lee, J.); Path Medical-Pines (a/a/o Evelyn Alonso) v. Progressive Select Ins. Co. [26 Fla. L. Weekly Supp. 331a], Case No. COWE 15023162 (81), Order Denying Defendant’s Motion for Final Summary Judgment (Broward Cty. Ct., March 22, 2018)(Fishman, J.); Plantation Spinal Care Center, Inc. v. Progressive Express Ins. Co., Case No. COCE 17005207 (51), Order on Defendant’s Motion for Final Summary Judgment (Broward Cty. Ct., Jan. 8, 2019)(McCarthy, J.).
