Volume 11

11 Fla. L. Weekly Supp. 259a

Insurance — Personal injury protection — Claim for magnetic resonance imaging filed by medical provider which provided technical component and paid radiologist to perform professional component of MRI on per reading basis — Patient brokering — There are no facts tending to show that a patient referral exists within the meaning of section 817.505(1), that circumstances do not fall within purview of professional consultation exception of section 817.505(3)(c) or that provider’s contractual arrangement with radiologist falls within purview of prohibitions on kickbacks set forth in section 456.054(1) and (2) — Rendering services — Where provider provided technical component of MRI, financed production of the professional component, transmitted the images to the radiologist, and received and transmitted the interpretation to the ordering physician and insurer, provider was involved in rendering complete professional service — Fee-splitting — Where contractual arrangement with radiologist assigns right to bill for radiologists services to medical provider and forbids direct billing by radiologist, there is no professional fee split since there is none charged by radiologist — Medicare Part B limiting charge is allowable charge within meaning of Florida No-Fault provision enacted in 2001 — Claim forms — Claim using CPT code without modifier to designate technical component is valid where insurer has made it impossible for technical components to be billed separately by failing to establish any specific reporting policies for separate billing of technical components — There is no misrepresentation in medical provider indicating that no outside lab was involved as term “outside lab” as used by Health Care Finance Administration does not refer to mere professional consultation service involving no technical testing service — Signature of physician — Argument that claim is invalid due to absence of a physician’s signature attempts to raise “properly completed” concept adopted in statute not yet in effect — Summary judgment granted in favor of provider

11 Fla. L. Weekly Supp. 877a

Insurance — Personal injury protection — Coverage — Medical bills — Unreasonable, unnecessary or unrelated medical expenses — No abuse of discretion in entering summary judgment for medical provider on insurer’s affirmative defense that medical services provided were not reasonable, related or necessary where provider offered affidavit of physician attesting that treatment was medically necessary and related to accident and that bill is for customary and reasonable charge, and insurer failed to present its own affidavit or other countervailing evidence — Statutory requirement that insurer first obtain medical report stating treatment was not reasonable, related or necessary before withdrawing payment of PIP benefits does not alter burden of proof in proceeding for summary judgment on issue of reasonableness, relatedness or necessity of treatment — Claim forms — Countersignature by insured — Assigned claim — Insured’s signature is not required on HCFA form where insured has assigned benefits to provider

11 Fla. L. Weekly Supp. 849a

Insurance — Personal injury protection — Claim form — Countersignature by insured — Assigned claim — Failure of insured to countersign claim forms is not valid affirmative defense under Florida PIP statute

11 Fla. L. Weekly Supp. 832a

Insurance — Personal injury protection — Coverage — Medical expenses — Insurer failed to create genuine issue of material fact regarding whether medical expenses were reasonable, related or necessary where provider/assignee filed deposition of treating physician establishing that physician is licensed and all treatment was reasonable, related, and medically necessary, and insurer filed affidavit of litigation adjuster stating that injuries were unrelated to accident because insured suffered from spina bifida — Claims — Countersignature by insured — Assigned claim — Insured’s failure to countersign medical bills does not relieve insurer of liability for payment of PIP benefits to medical provider who has accepted assignment of benefits — No merit to affirmative defense of lack of proper licensing of medical provider where insurer has failed to specifically allege that it has proof that treatment was rendered by physicians without proper licenses to perform treatment or rendered unlawfully by therapists, there is no requirement that provider submit licenses with bills, and insurer has failed to offer any evidence to rebut affidavits of physician and billing clerk asserting proper licensing — Fraud — Affirmative defense of fraud is stricken where insurer failed to plead fraud properly and has failed to provide any record evidence of fraud — Summary judgment entered in favor of provider

11 Fla. L. Weekly Supp. 790b

Insurance — Personal injury protection — Claim form — Countersignature by insured — Assigned claim — Insured was not required to countersign medical bills where insured has assigned PIP benefits to medical provider

11 Fla. L. Weekly Supp. 508a

Insurance — Personal injury protection — Claim form — Signature of physician — Countersignature — Assigned claim — Statute does not require signature or credential of provider on HCFA-1500 form, nor does it require insured’s countersignature on form where there is valid assignment of benefits — Order granting summary judgment in favor of provider/assignee is affirmed where insurer’s sole basis for nonpayment of bills was absence of signature and countersignature on claim forms

11 Fla. L. Weekly Supp. 204b

Insurance — Personal injury protection — Claim forms — Countersignature — Section 627.736(5)(a) does not require signature of insured on claim form where insured has assigned benefits to plaintiff medical provider — Coverage — Denial — Unreasonable, unrelated or unnecessary medical expenses — No abuse of discretion in entering summary judgment in favor of insured on issue of whether treatment for which reimbursement was sought was reasonable, related to accident, and necessary where only evidence presented to rebut treating physician’s affidavit stating PIP benefits sought were reasonable, related to accident, and necessary for treatment was letter of claims adjuster stating that physician who conducted independent medical examination opined that any further medical treatment would not be reasonable, related or medically necessary, which is hearsay and not competent evidence

11 Fla. L. Weekly Supp. 195a

Insurance — Personal injury protection — Claim forms — Countersignature — Section 627.736(5)(a) does not require signature of insured on claim form where insured has assigned benefits to plaintiff medical provider — Coverage — Denial — Unreasonable, unrelated or unnecessary medical expenses — No error in denial of motion for directed verdict arguing that there is no evidence that insured was in motor vehicle accident where insurer’s answer, read in light most favorable to medical provider, admitted and did not contest that insured was in motor vehicle accident, and treating physician testified that insured sought treatment for injuries suffered in automobile accident — Appellate fees awarded

11 Fla. L. Weekly Supp. 4b

Insurance — Personal injury protection — Claim forms — Countersignature — Section 627.736(5)(a) does not require HCFA forms to be countersigned by insured when the medical provider has accepted an assignment of benefits — Summary judgment in favor of insurer reversed and remanded — Attorney’s fees awarded to medical provider contingent on prevailing on recovery on policy

11 Fla. L. Weekly Supp. 1013b

Insurance — Personal injury protection — Coverage — Denial — Improper coding — Insurer has failed to prove that treatment provided by provider/assignee was improperly coded where testimony of insurer’s expert witness on coding was severely undercut by fact that insurer did not dispute coding in explanation of benefits and only raised challenged coding over a year later when insurer sought leave to amend its affirmative defenses