Medical Providers: What You Shouldn’t Put Up with from Insurance Companies

The 11th Judicial Circuit in and for Dade County recently ruled on an evidentiary issue. This evidentiary issue pertains to affidavits. Black’s Law Dictionary (5th Ed.) defines an affidavit as,

“A written or printed declaration or statement of facts, made voluntarily, and confirmed by the oath or affirmation of the party making it, taken before an officer having authority to administer such oath.”

In the context of motions for summary judgment, plaintiff attorneys representing medical providers will usually procure written statements from their medical providers stating that all treatment rendered to the patient was medically necessary, related and reasonable in connection with the patient’s car accident. Defense attorneys will request that their claims adjuster or medical expert sign a written affidavit alleging that the medical treatment was not medically necessary or that the charges for medical services weren’t reasonable. The court in Hialeah Medical Association, Inc. v. United Automobile Insurance Company, had many important issues to decide. The main issue in the case was whether or not United Automobile Insurance Company’s policy elected to rely on the Medicare fee schedule or whether the policy was silent as to what reimbursement method was proper.

Facts in the Case of a Medical Association vs. an Insurance Company

Ana Lexcano sustained injuries in connection with an automobile accident that occurred on June 23, 2008. Ms. Lexcano sought treatment for her injuries at Hialeah Medical. Hialeah Medical sent medical bills for the treatment rendered to Ms. Lexcano to her automobile insurer, United Auto. United Automobile received Hialeah Medical’s demand letter and indicated that the charges Hialeah submitted for payment were greater than the amount that is allowed pursuant to the Medicare Part B Fee Schedule. United paid Hialeah Medical $1,183.18, which represents 80% of the Medicare Part B fee schedule for the bills. Hialeah did not cash the check, as they maintained that the payments were incorrect in that United should have paid Hialeah 80% of the total charges for treatment rendered to Ms. Lexcano, instead of the payment reimbursed to Hialeah Medical by United (80% of the Medicare part B Fee Schedule).

Hialeah Medical moved for summary judgment arguing that its bills were reasonable, related and necessary in connection with Ms. Lexcano’s automobile accident. United Automobile countered by filing its litigation adjuster’s affidavit, stating that Hialeah’s chargers were in excess of the usual and customary fees allowed by the Medicare fee schedule. Hialeah argued that the Medicare Part B Fee Schedule should not be the indicator as to whether Hialeah’s bills were or were not reasonable. Hialeah’s main argument was that United did not indicate in its policy, that they were relying on the Medicare Part B fee schedule.

On June 6, 2011, the trial court held that Hialeah was to be awarded $1,478.92, which represented four or five cents less than the amount paid by United Auto. The trial court entered a final judgment in favor of United Auto, indicating that 80% of what the court awarded is four cents less than United Auto’s pre-suit payment. A re-hearing occurred, and the trial court eventually entered an order vacating the final judgment decided in favor of United Auto.

Pricing Medical Bills

The 11th Circuit Appellate Court for Dade County was tasked with deciding whether or not the trial court should have denied Hialeah Medical’s supplemental motion to decide pricing and reasonableness of the prices they charged for the medical treatment rendered to Ms. Lexcano.

United Auto. admitted to using the Medicare Part B Fee Schedule to determine payment to Hialeah Medical. However, Ms. Lexcano’s policy was purchased in 2007. Importantly, prior to 2008 Medicare fee schedules were not relevant in PIP cases. Likewise as important, an insurer has to elect the use of the Medicare fee schedule in its policy to use the fee schedule when determining what to reimburse a medical provider, like Hialeah Medical. Moreover, the affidavits of the adjusters admitted to relying on the Medicare fee schedule.

The court further held that United Automobile failed to elect to rely the Medicare fee schedule in its policy. United’s policy was not amended until July 2012. Thus, the court held that United Automobile was prohibited from relying on the 2008 Medicare fee schedule in response to the motion for summary judgment filed by Hialeah Medical. Final judgment was entered in favor of Hialeah Medical.

How This Ruling Applies to Medical Providers

Although the policy at issue in the Hialeah Medical case was purchased in 2007, prior to Medicare fee schedules becoming an allowable reimbursement in PIP, the county court in its appellate capacity did in fact hold that United Automobile failed to elect to rely on the Medicare fee schedule in its policies. Medical Providers should feel comfortable billing their usual and customary charges for services. They should expect reimbursement for 80% of their reasonable and medically necessary medical services/bills, as United Automobile did not amend their PIP insurance policy provisions until 2012. Moreover, adjusters’ affidavits will not be allowed, unless they are based on relevant or sufficient data as the Lexcano court opined. An adjuster cannot simply state that a medical provider’s charges are not usual and customary; they must back these contentions up with sufficient data. Mere contentions by claims adjusters will not suffice!


It is crucial that a medical provider contact an experienced PIP litigation attorney to discuss important matters, such as proper payments for medical services and corresponding billing. Many times, the insurer will pay an incorrect amount, despite knowledge of the error. As the court in Lexcano held, despite United Auto’s contentions, their policy did not elect to choose the Medicare part B fee schedule as proper reimbursement for medical services/treatment. However, United Automobile continues to pay pursuant to the Medicare Part B fee schedule for services, and unless one litigates these issues, the payments will remain incorrect!

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