Coastal Neurology, Inc. v. State Farm Mutual Automobile Insurance

271 F.R.D. 538, 78 Fed. R. Serv. 3d 21, 2010 U.S. Dist. LEXIS 128031, 2010 WL 4878573
CourtDistrict Court, S.D. Florida
DecidedNovember 30, 2010
DocketNo. 10-60354-CIV
StatusPublished
Cited by6 cases

This text of 271 F.R.D. 538 (Coastal Neurology, Inc. v. State Farm Mutual Automobile Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Coastal Neurology, Inc. v. State Farm Mutual Automobile Insurance, 271 F.R.D. 538, 78 Fed. R. Serv. 3d 21, 2010 U.S. Dist. LEXIS 128031, 2010 WL 4878573 (S.D. Fla. 2010).

Opinion

[541]*541 ORDER ON MOTION FOR CLASS CERTIFICATION

URSULA UNGARO, District Judge.

THIS CAUSE is before the Court upon Plaintiffs Motion for Class Certification, filed July 2, 2010 (the “Motion”) (D.E. 41.) Defendant responded on August 13, 2010 (the “Response”) (D.E. 55), and Plaintiff replied on August 30, 2010 (D.E. 69.) Also before the Court is Plaintiffs Motion to Strike Defendant’s Opposition to Plaintiffs Motion for Class Certification, filed August 18, 2010 (D.E. 63.)

THE COURT has considered the Motions and the pertinent portions of the record and is otherwise fully advised in the premises.

I. Background

The issue in this case is whether State Farm Mutual Automobile Insurance Company’s (State Farm) use of National Correcting Coding Initiative edits to limit providers’ reimbursements violates Florida’s No-Fault Law, Fla. Stat. § 627.736 (the “No-Fault Statute.”)

A. Parties

State Farm is an insurance carrier that sells No-Fault or Personal Injury Protection (“PIP”) coverage (Am.Compl. ¶ 9.) Coastal Neurology (“Coastal”) provides healthcare services to individuals covered under State Farm’s No-Fault policies and bills State Farm pursuant to assignments of benefits (Am.Compl. ¶ 20.)

B. Statutory Framework

Florida’s No-Fault Statute is designed to provide insurance without regard to fault. Fla. Stat. § 627.731 (2006). Every policy under the No-Fault Statute must provide up to $10,000 for loss sustained as a result of “bodily injury, sickness, disease, or death arising out of ownership, maintenance, or use of a motor vehicle....” Fla. Stat. § 627.736(1).

1. Type of Reimbursements Permitted

Section (l)(a) provides that insurers must reimburse eighty percent of all “reasonable expenses for medically necessary” healthcare services (emphasis added). Section (5)(a) states that a provider may reimburse “only reasonable amount[s]” and only those amounts that appear on an invoice, bill or claim form that has been “properly completed” (emphasis added). Section 5(d) provides guidelines an insured or her provider must follow in order to submit a properly completed bill.

2. Permitted Limitations on Reimbursement Amounts

Pursuant to section (5)(a)(2), an insurer may limit reimbursement to 80% of “200 percent of a the allowable amount under the participating physicians schedule of Medicare Part B.” Section (5)(a)(3) adds that, for purposes of subparagraph (2), “the applicable fee schedule ... under Medicare is the fee schedule

in effect at the time the services, supplies, or care was rendered and for the area in which such services were rendered, except that it may not be less than the allowable amount under the participating physicians schedule of Medicare Part B for 2007 for medical services, supplies, and care subject to Medicare Part B.”

Fla. Stat. § 627.736(5)(a)(3). This means that the applicable fee schedule for maximum charges for the current year must be compared with the applicable schedule for 2007, and the insurer must pay the higher of the two.

Pursuant to section (5)(a)(4), a provider may not apply the following three limits on reimbursements:

limitation on the number of treatments ... [2] utilization limits that apply under Medicare or workers’ compensation. An insurer ... must reimburse a provider who lawfully provided care or treatment under the scope of his or her license, regardless of whether such provider would be entitled to reimbursement under Medicare due to restrictions or [3] limitations on the types or discipline of health care providers who may be reimbursed for particular procedures or procedure codes.

[542]*542Fla. Stat. § 627.736(5)(a)(4) (emphasis added).

C. National Correct Coding Initiative Edits

The Centers for Medicare and Medicaid Services developed the National Correct Coding Initiative (NCCI).1 The NCCI’s goal is to “promote national correct coding methodologies and to control improper coding [of healthcare services] leading to inappropriate payment in [Medicare] Part B claims.”2 The purpose of NCCI edits is “to prevent improper payment when incorrect code combinations are reported.”3 NCCI edits exist for a wide range of healthcare services.4

A modifier is a two-digit code that further describes the health services performed.5 Providers may include one or more of the thirty-five available modifiers in their bill to bypass an NCCI edit.6 For example, a provider may bill for two services in an NCCI code pair and include a modifier that would override the edit and allow a reimbursement for both services.7

D. Individual and Class Allegations

Coastal alleges that State Farm violates the No-Fault Statute by using NCCI edits to reduce and deny reimbursements to it and similarly situated healthcare services providers (Am.Compl. ¶ 24.) Coastal charged State Farm for services pursuant to the policy assignment of a State Farm policyholder (“Policyholder”) who sought treatment at Coastal after sustaining injuries in an automobile accident (Am.Compl. ¶¶ 21-22.) Among the healthcare services Coastal billed State Farm for are those for which the service coded is 97124 (Am.Compl. ¶¶ 22.) Coastal alleges that pursuant to the No-Fault Law, State Farm was required to pay it 200% of the Medicare Part B Fee Schedule for the service; however, State Farm improperly applied an NCCI edit to reduce the reimbursement to zero (Am.Compl. ¶¶23-22.) Coastal has sued State Farm for breach of contract (Count 1) and declaratory judgment (Count 2) (See Am.Compl. ¶¶ 36-46 & 47-57.)

Coastal seeks an order certifying the following two classes — a class for each count in the Amended Complaint:

Class for Count 1: All Florida healthcare providers which obtained an assignment from a State Farm Insured and have claims for services rendered to State Farm insureds that were reduced or not paid based on the National Correct Coding Initiative edit database who submitted a written intent to initiate litigation under § 627.736(10), which was rejected by State Farm.
Class for Count 2: All Florida healthcare providers which have claims for services rendered to State Farm insureds that were reduced or not paid based on the National Correct Coding Initiative edit database.

Motion at 3 (additional emphasis added). Coastal asks this Court to certify the classes pursuant to Federal Rule of Civil Procedure

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271 F.R.D. 538, 78 Fed. R. Serv. 3d 21, 2010 U.S. Dist. LEXIS 128031, 2010 WL 4878573, Counsel Stack Legal Research, https://law.counselstack.com/opinion/coastal-neurology-inc-v-state-farm-mutual-automobile-insurance-flsd-2010.