95 So. 3d 903
Fla. Dist. Ct. App.2012Background
- SOCC provided treatment to Badillo and Garcia for car accident injuries and assigned rights to PIP benefits to SOCC.
- SOCC billed State Farm; State Farm paid only part of the charges under NCCI-based reasoning.
- Lower court granted summary judgment to State Farm, finding unbundling of services violated NCCI edits.
- Florida No-Fault Statute § 627.736(5) governs insurer reimbursement limits and which schedules apply.
- Question certified asked whether NCCI edits are incorporated into Florida No-Fault Statute; court answers no.
- Court concludes the NCCI edits are not incorporated; case reversed and remanded for judgment in SOCC's favor.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Are NCCI edits incorporated into Florida No-Fault Statute? | SOCC argues NCCI not incorporated; only participating physicians schedule applies. | State Farm argues NCCI edits are incorporated via Medicare pay system in No-Fault statute. | NCCI edits are not incorporated. |
| Does reference to OIG incorporate NCCI edits into No-Fault Statute? | OIG endorsement would import NCCI into No-Fault. | OIG reference does not import NCCI into No-Fault. | OIG reference does not incorporate NCCI. |
| What is the proper interpretation of § 627.736(5)(a) with respect to Medicare guidelines? | Legislature intended broader Medicare-based limits including NCCI. | Legislature intended only the participating physicians schedule; Medicare guidelines beyond that are not adopted. | The statute adopts only the participating physicians schedule; Medicare/NCCI limits are not applicable. |
Key Cases Cited
- Allstate Ins. Co. v. Holy Cross Hosp., Inc., 961 So.2d 328 (Fla.2007) (legislative intent is guided by statute language)
- All Family Clinic of Daytona Beach Inc. v. State Farm Mut. Auto. Ins. Co., 685 F.Supp.2d 1297 (S.D. Fla.2010) (court held no incorporation of full Medicare into No-Fault; only Part B schedule limits apply)
- Nationwide Mut. Fire Insurance Co. v. AFO Imaging, Inc., 71 So.3d 134 (Fla. 2d DCA 2011) (OPD/Medicare schedules distinguished; MRI limits not tied to OPD in No-Fault)