Injury Protection Litigation (PIP) in Florida has been a high volume practice area. Unfortunately, the number of PIP prosecutions may increase even more due to recent court rulings.
The decision of the Third District Court of Appeal (DCA) in Priority Medical Centers, LLC a / a / o Susan Boggiardino v. Allstate Insurance Company, upheld the 2012 changes to the Florida No-Fault Act requiring the carrier to reimburse a diagnostic imaging supplier in accordance with the 2007 non-limiting fee. The court ruled that this applies when the amount exceeds the fee schedule of participating physicians. The ruling will likely have a negative impact on insurance companies’ liability for potential underpayment in almost all claims in the past five years in which an X-ray or MRI code has been reimbursed in accordance with the fee schedule. participating physicians.
Understanding the limit load
The limitation fee is a higher limit, or cap, for medical providers who do not accept the Medicare-approved amount as full payment. A medical provider may request a higher reimbursement from Medicare in these cases. The limitation fee would dictate the maximum amount allowed once approved. These additional costs are limited to 15% more than the reimbursement approved by Medicare. However, states can choose to set a lower limit. This different reimbursement rate has since created a wave of PIP lawsuits, mostly on behalf of diagnostic imaging vendors. These new lawsuits demand a higher reimbursement for previously paid services. This surge is expected to intensify over the coming months.
In 2004, the Third District Court of Appeal heard argument in the case of Millennium Diagnostic Imaging Center v. Security National Insurance Company. In Millennium, the court ruled that an insurance company chose to limit reimbursements under the PIP to the amounts allowed by the Medicare Part B fee schedule, reimbursement would be limited to 80% of 200% of the price of the non-participating establishment and not at the limitation fee. The court based its decision on the wording of Florida’s PIP Act using the phrase “Participating Physician Fee Schedule.” In 2003, the Florida legislature deleted “applicable” and added “participating physician fee bar”, under §627.736 (5) (a) (2) (2003). The court in Millennium Diagnosis held “we believe the amendment was adopted to clarify the intention of the legislature on what would be an ‘eligible amount’. “
However, in 2012, the Florida legislature amended the PIP Act and replaced the term “participating physician” with the word “applicable”. As a result, medical providers began to argue that the opinion of the Millennium Diagnosis court was no longer valid. The argument was that the legislative intention of the amendment was to provide a higher refund whenever a CPT code was redeemable at an amount below the 2007 limit charge. Priority medical centers analyzed the current version of the PIP statute with the 2012 amendment and decided that the Medicare Part B “eligible amount” is the limit charge for 2007 if that amount is greater than the off-facility price. Priority Med. Ctr.
In addition, Florida PIP law states that reimbursement cannot be less than the amount allowed under the 2007 Medicare fee schedule. The Third District Court of Appeal upheld this opinion. The decision has now made the charge rate limit the Medicare-approved reimbursement fee schedule. Under current Florida law, limitation fees are now the appropriate reimbursement measure in determining reimbursement when the 2007 amount is greater than the participating physician’s fee schedule.
The point to remember for insurance companies is the reimbursement which was previously an appropriate reimbursement has now been retroactively made insufficient. As a result, most past reimbursements of an MRI code, X-ray code, or any other CPT code in which the reimbursement was less than the 2007 fee limit are now inappropriate. In addition, exposure to potential attorney fees and costs has now increased exponentially.
There has already been a huge increase in lawsuits filed on behalf of establishments that provided the types of diagnostic services that are affected by the court ruling in Priority Mean Ctr. This trend is likely to increase in the coming months. The only way for a carrier to protect itself in this new landscape is to provide the additional benefits in response to the legal notice. Otherwise, a carrier faces additional lawsuits in which they will likely be held liable not only for the additional benefits, but also attorney fees / costs.
Alexander J. Mendez is a member of the Accident Department in the Fort Lauderdale office of Marshall Dennehey Warner Coleman & Goggin, where he focuses on PIP litigation and other matters relating to auto litigation, premises liability and general corporate affairs. ‘accidents. He can be reached at (954) 905-3801 or [email protected].
The opinions expressed here are those of the author.