Recent 4th DCA Decision: A Winner for medical Providers

A recent decision by Florida’s Fourth District Court of Appeal (4th DCA) is a winner for medical providers who have had services denied by a Personal Injury Protection (PIP) insurer because the code billed does not have an established reimbursement amount under Medicare or Florida Workers’ Compensation. The case was a consolidated appeal requesting reversal of the trial court’s order in favor of MD Now Medical Centers, Inc. which required insurers to reimburse MD Now for billed urgent care center facility fees under Code S9088. (See Safeco Ins. Co. v. MD Now Med. Ctrs., Inc., Nos. 4D22-846, 4D22-847, 4D22-1486, 2023 Fla. App. LEXIS 5401, at *1 (4th DCA Aug. 2, 2023) )

In each of three cases, the insureds were injured in automobile accidents and received treatment at one of MD Now’s urgent care centers. Each of the insureds assigned their PIP benefits to MD Now. MD Now submitted medical bills to the insurers, who paid all charges except for the urgent care facility fee under Code S9088. MD Now uses this code to bill for services provided in an urgent care center.

The insurers denied payment of Code S9088, claiming it wasn’t a covered expense pursuant to Section 627.736(5)(a)(1)(f), Florida Statutes because it is not reimbursable under either the Medicare or Florida’s Workers’ Compensation Fee Schedules. The insurers asserted that (i) neither Medicare nor Workers’ Compensation have a set fee for Code S9088, and (2) Workers’ Compensation reimburses urgent care centers using the non-facility Maximum Reimbursable Amount (“MRA’).

MD Now argued that Code S9088 was reimbursable under Workers’ Compensation and the Florida Workers’ Compensation Health Care Provider Reimbursement Manual. MD Now contended that codes that do not have a set MRA require insurers to have an established methodology for determining the reimbursement amount. MD Now submitted evidence that Workers’ Compensation insurers consistently reimbursed for Code Sgo88 in the three years prior to the filing of this lawsuit and that Workers’ Compensation insurers have repeatedly used Code S9088 since 2002 when the code first went into effect.

The 4th DCA looked to the language of the PIP statute, specifically Section 627.736(5)(a)(1)(f), Florida Statutes, which states in pertinent part: “…if such services, supplies, or care is not reimbursable under Medicare Part B, as provided in this subparagraph, the insurer may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation, as determined under s. 440./3 and rules adopted thereunder which are in effect at the time such services, supplies or care is provided. Services, supplies or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by the insurer.”

The question presented to the 4th DCA was whether, under Section 627.736(5)(a)(1)(f), Florida Statutes, Code S9088 is a type of service which is reimbursable under Workers’ Compensation such that a PIP insurer is required to pay those charges.

The 4th DCA affirmed the lower courts’ decisions, holding that reimbursement of Code S9088 is permitted “under a plain reading of the statutes, regulations and applicable reference guide provision.” In their decision, the Court explained that, in conjunction with Section 440.13, Florida Statutes, the Florida Administrative Code Rule 69L-7.020 adopts the Florida Workers’ Compensation Health Care Provider Reimbursement Manual. The Manual stipulates that if a code does not have an established Maximum Reimbursable Amount (“MRA’), the insurer must have a methodology for determining reimbursement for that code that is done by comparing the billed code(s) with clinically similar codes found in the Current Procedural Terminology (CPT) Manual or the Healthcare Common Procedure Coding System (HCPCS) Manual. This means that codes like Code S9088, which do not have established MRA’s, still must be reimbursed by Florida PIP insurers. The 4th DCA’s decision will allow medical providers to be compensated if they were previously denied reimbursement for Code S9088 and for other codes that were denied for the same reason. Currently, the 4th DCA is the only Florida DCA to have ruled on this issue, which means that it applies to the entire State of Florida, unless and until another DCA issues a conflicting opinion.