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CASE REVIEW: PAN AM DIAGNOSTIC V. STATE FARM: STATE FARM’S POLICY STRICKEN AS VAGUE!!!

July 27, 2015 4:26 pm | Categorised in:

Gavel and BooksOn April 30, 2015 the 11th Judicial Circuit in and for Miami-Dade County held that State Farm’s policy failed to clearly elect the use of the multiple procedure payment reduction rule. The Honorable Judge Linda Singer Stein opined that State Farm’s policy and procedures were vague and ambiguous as to whether it could reduce payment to less than 200% of the Medicare Physicians Fee Schedule for 2007. This decision is important in light of the new PIP law that went into effect in 2012 and 2013. The new PIP law allows insurers to utilize Medicare Coding Methodologies. However, an insurer must give its customers/insureds notice of its election to incorporate alternative payment methods.

The 11th Judicial Circuit reaffirmed the holding in Kingsway Amigo Insurance Company v. Ocean Health, Inc. A/a/o Belizaire Gomez, 36 Fla. L. Weekly D1062a (Fla. 4th DCA 2011), holding that the insurer must elect a fee schedule methodology with clear and unambiguous language. If State Farm chooses to utilize the MPPR payment methodology, it must “clearly and unambiguously elect to pay pursuant to the MPPR. “

FACTS: Cristina Lasaga was injured in a motor vehicle accident on August 29, 2013. She had a Personal Injury Protection policy with State Farm Mutual Automobile Insurance Company to which she assigned her benefits under the policy to Pan Am Diagnostic Services, Inc. .She sought treatment with Pan Am Diagnostic Services, Inc.  and received a cervical MRI and a lumbar MRI.

State Farm reimbursed the Provider $672.80 for the neck MRI and $1,206.66 for the low back MRI. Both MRI’s were performed on the same day. State Farm reimbursed the Plaintiff Provider pursuant to the Medicare Multiple Procedure Payment Reduction rule (“MPPR”). The court had to decide whether State Farm’s policy form 9810A clearly and specifically elected the permissive fee schedule reimbursement methodology or clearly and specifically elected to pay according to a different, and lower, reimbursement method, the Multiple Procedure Payment Reduction, also known as MPPR.

Defendant filed a Motion for Summary Judgment and the Plaintiff Cross-Noticed their Summary Judgment.

Arguments:

  1. Plaintiff argued that State Farm’s policy clearly stated that it will pay 80% of the allowable amount under the participating physicians’ fee schedule of Medicare Part B. The policy further states that it will not make a payment less than the allowable amount under the applicable schedule of Medicare Part B for 2007 for medical services and care subject to Medicare Part B. Thus, Plaintiff argued the MPPR cannot apply because it would result in a reimbursement less than what State Farm promises in their policy.
  2. Defendant argued that their policy allows Medicare coding despite failing to include language specifically allowing them to elect to utilize MPPR payment methodologies. They further argued that the same language allowed them to limit PIP reimbursements below the allowable amount under the 2007 Medicare Part B physicians fee schedule, based on the MPPR.

Court’s Decision

Honorable Judge Linda Singer Stein ruled in favor of the Plaintiff. She held that State Farm’s policy clearly elected to pay pursuant to the permissive fee schedule found in Florida Statutes Section 627.736(5)(a)(1)(f). Thus, State Farm had an obligation to pay its insured pursuant to that payment methodology. The Court held that Defendant’s policy does not permit it to, “limit its reimbursement to the Plaintiff to less than 80% of the allowable amount under the 2007 Medicare Part B fee schedule. State Farm failed to clearly elect the MPPR reduction.” State Farm failed to include specific language about the MPPR reduction within its policy.

HOW IT HELPS YOU

If your insured assigns benefits under a new State Farm policy, send us the EOBs to determine whether or not State Farm has utilized MPPR reductions. State Farm’s policy lacks a clear and unambiguous election and as such you are entitled to reimbursement pursuant to either the 2007 Medicare Part B fee schedule or the fee schedule for the year in which the services were rendered.[1] We will file our Motions and ensure that you receive a full reimbursement for the necessary medical services you provide!

Image courtesy of FreeDigitalPhotos.net by hywards

[1] The greater of the two fee schedules.