According to a statement from the Florida Department of Financial Services, Dr. Celestino Santi was arrested for allegedly defrauding nine auto insurance companies our of more than $500,000 in unlicensed medical billing.
Investigators reveal that Santi was allegedly acting as a “straw owner” of Accident Care Center of Boggy Creek to disguise the identity of the unlicensed, true owner of the motor vehicle accident medical treatment center.
Click here to read the article.
Filed under Fraud, Personal Injury Protection (PIP)
The New York State Department of Financial Services (“DFS’) has finalized the Thirty-Third Amendment to Regulation 83 (the “33rd Amendment”), which was published in the State Register on October 25, 2017 and will affect treatment rendered on or after January 23, 2018. Pursuant to the accompanying press release, the 33rd Amendment is designed to “limit the amount that insurers can reimburse for healthcare services performed outside of New York State under its no-fault insurance law.”[1] By limiting reimbursement amounts for out-of-state no-fault healthcare services, which are treating New York State (“NYS”) residents, the DFS intends to “curb costs and abuses” by out-of-state medical providers charging excessive rates.[2].
Regulation 83, governing the reimbursement of out-of-state providers, previously provided that:
“If a professional health service is performed outside New York State, the permissible charge for such service shall be the prevailing fee in the geographic location of the provider.” (11 NYCRR § 68.6).
The case of Surgicare Surgical Assoc. v National Interstate Ins. Co., 2014 WL 6610048, 2014 N.Y. Slip Op. 24362) (Anthony Cannataro, J.), provides a good example of an out-of-state provider seeking reimbursement at an exorbitant rate, diminishing the coverage available to the insured for other medically necessary services. There, the provider performed arthroscopic surgery on a covered person in New Jersey and submitted a claim for reimbursement under the applicable New York No-fault policy. Although the state of New Jersey has a fee schedule that applies to the reimbursement of medical services under the New Jersey’s No-fault law, the provider submitted a bill to the insurer for approximately $5,000 more than the amount it would have been reimbursed had the claim involved a New Jersey auto policy and as a result, was governed by the New Jersey fee schedule. The insurer reimbursed the amount permitted under the New Jersey fee schedule, essentially maintaining that, pursuant to Regulation 83, the New Jersey fee scheduled reflected the permissible amount in the geographic area. The provider sued for the difference. After discussing the applicable regulations and policy considerations behind the enactment of the New York No-fault law, including the legislative intent of cost containment, a New York City Civil Court judge held that, “when services are rendered outside of New York but in a jurisdiction which utilizes a fee schedule, the insurer complies with Section 68.6 by paying the ‘permissible’ charge for that particular medical service, that is, the amount permitted by that jurisdiction’s fee schedule.” The provider appealed and the Appellate Term affirmed. See Surgicare Surgical Assoc. v National Interstate Ins. Co., 2015 NY Slip Op 25338 (App. Term 1st Dept. 2015).
In other instances, the amount sought by out-of-state providers has been tens of thousands of dollars above the amount that would be permitted under the New York Fee Schedule. Recognizing the potential for fraud and abuse, the Amendment provides an effective solution to the exploitation of the No-fault system by out-of-state providers and, adopts, to some extent, the holding in Surgicare and, by regulation, strengthens the limits placed on reimbursement of such providers. Specifically, the Amendment states:
11 NYCRR 68.6: Health services performed outside New York State
(a)(1) If a professional health service reimbursable under [section 5102(a)(1) of the] Insurance Law section 5102(a)(1) is performed outside this State, the amount that the insurer shall reimburse for the service shall be the lower of the amount charged by the provider and the prevailing fee in the geographic location of the provider with respect to services:
(i) that constitute emergency care;
(ii) provided to an eligible injured person that is not a resident of this State; or
(iii) provided to an eligible injured person that is a resident of this State who, at the time of treatment, is residing in the jurisdiction where the treatment is being rendered for reasons unrelated to the treatment.
(2) For purposes of this subdivision, emergency care means all medically necessary treatment initiated within 48 hours of a motor vehicle accident for a traumatic injury or a medical condition resulting from the accident, which injury or condition manifests itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Medically necessary treatment shall include immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends during the period of initial hospitalization until the patient is discharged from the hospital.
(b) Except as provided in subdivision (a) of this section, if a professional health service reimbursable under Insurance Law section 5102(a)(1) is performed outside this State with respect to an eligible injured person that is a resident of this State, the amount that the insurer shall reimburse for the service shall be the lowest of:
(1) the amount of the fee set forth in the region of this State that has the highest applicable amount in the fee schedule for that service;
(2) the amount charged by the provider; and
(3) the prevailing fee in the geographic location of the provider.
(c) If the jurisdiction in which the treatment is being rendered has established a fee schedule for reimbursing health services rendered in connection with claims for motor vehicle-related injuries and the fee schedule applies to the service being provided, the prevailing fee amount specified in subdivisions (a) and (b) of this section shall be the amount prescribed in that jurisdiction’s fee schedule for the respective service.
The 33rd Amendment separates treatment by out-of-state medical providers into the following two categories:
There is one main difference between the two categories – which State’s no-fault fee schedule governs and must be utilized by the insurer when reimbursing the medical provider. Simply put, if the medical services fall into Category 1, the medical provider’s reimbursement will be capped at the No-Fault Schedule rate for the State and region wherein the services are provided. By contrast, if the medical services fall into Category 2, the medical provider’s reimbursement will be capped at the highest rate available under the New York State No-Fault Fee Schedule unless the State where the treatment is being rendered has an established fee schedule for claims related to motor vehicle-related injuries.
As such, section (c) of 11 NYCRR 68.6 would apply to medical services rendered in Florida as there is an established set of fee schedules within the Florida No-Fault Law. While the foregoing may be the general rule, there are nuances requiring attention.
The reimbursement rate for medical services is now capped at the prevailing fee in the geographical location of the provider unless the provider charges less. Thus, the 33rd Amendment now limits the prevailing geographical rate to that area’s local No-Fault Fee Schedule Rate. In other words, if x-ray services are performed in Miami, Florida the provider’s reimbursement is limited to the schedule of maximum charges as listed in the Florida No-Fault law for that geographical region (Miami) (i.e, 200% of Medicare Part B).
The medical providers and insurers also need to be familiar with the amendment’s definition of what constitutes “emergency care”’ and how it relates to reimbursement.
Example 1: If a person is transported to the Hospital as a result of a motor vehicle accident in Florida and that person lives in Florida but is covered by a New York policy, then that Hospital provider’s charges would be limited to 75% of the usual and customary charge pursuant to the Florida No-Fault Law’s schedule of maximum charges. Moreover, the emergency services doctor would be paid at its usual and customary charge which is generally the submitted charge.
Example 2: Compare to the facts that this same individual is involved in a motor vehicle accident in Florida on January 1, 2019 and is not transported to the Hospital. However, three days later they decide to go to the emergency room due to having neck and back pain related to the accident. Would these Hospital and physician services now be considered “emergency care”? Under this amendment, it would not because the treatment was not initiated within 48 hours following the accident.
Now further compare these facts with the applicable schedule of maximum charges under Florida Statute §627.736(5) (2018) which states in pertinent part:
The insurer may limit reimbursement to 80 percent of the following schedule of maximum charges:
a. For emergency transport and treatment by providers licensed under chapter 401, 200 percent of Medicare.
b. For emergency services and care provided by a hospital licensed under chapter 395, 75 percent of the hospital’s usual and customary charges.
c. For emergency services and care as defined by s. 395.002 provided in a facility licensed under chapter 395 rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community.
d. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services.
e. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.
In the situation listed in Example 2, the patient’s condition would not be considered “emergency care” and thus, payment would be made at 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services or 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.
Conclusion
In order to maximize recovery without running afoul of the new fee schedule mandates of the 33rd Amendment, Florida medical providers treating patients covered by New York No-Fault policies must be cognizant of whether the service rendered meets the definition of “emergency care.” What this amendment does clarify is that if medical services are rendered in Florida under a PIP claim brought under a New York policy, then the maximum amount to be paid to the medical providers for these services would be limited to Florida’s schedule of maximum charges.
[1] Press Release, posted October 10, 2017, http://www.dfs.ny.gov/about/press/pr1710101.htm
[2] Id.
[3] Under the 33rd Amendment, in order to constitute emergency care, the treatment must be initiated within 48 hours of the motor vehicle accident.
This article is not intended to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that require attention.
For additional information, please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com.php73-37.phx1-1.websitetestlink.com. Stephen G. Mellor is a partner in the Deerfield Beach office of Roig Lawyers who primarily focuses on out-of-state policy claims for insurance carriers.
Filed under Personal Injury Protection (PIP)
Andrew Rubinstein of Miami and the self-confessed ringleader, Felix Filenger of Sunny Isles pleaded guilty to a racketeering conspiracy charge last year. Rubinstein and Filenger were paying kickbacks to tow truck drivers and body shop workers who illegally steered accident victims to chiropractic clinics they owned at a rate of $1,500 to $2,000 per “patient.” Clinic workers would then have patients attend multiple visits, document exaggerated pain levels, and bill insurance providers for treatment in the amount of $10,000, the maximum allowed under Florida law.
According to Prosecutors, the clinics were located throughout south and central Florida, including Sunrise, Hollywood, Hallandale Beach, Pompano Beach, Delray Beach, West Palm Beach, Miami, Orlando and Kissimmee.
Under the terms of his plea agreement, both sides had agreed to recommend the six-year sentence for Rubinstein. Filenger’s sentencing has been postponed. Several other people who also admitted their roles in the fraud are scheduled for sentencing later this year.
Click here to view the full article. (Previous post)
Filed under Fraud, Personal Injury Protection (PIP)
ROIG Lawyers Attorneys Cecile S. Mendizabal and Lissette M. Alvarez published the article, “Ridesharing Legislation May Trigger New Wave of Litigation” in the Daily Business Review.
ROIG Lawyers Summer Law Clerk Yasbel Perez also contributed to the article.
Subscription required for full article.
Filed under Legislation, Personal Injury Protection (PIP)
According to Law360, on Wednesday, April 19th Florida’s Third District Court of Appeal retroactively applied a state Supreme Court decision involving Allstate Insurance Co.’s personal injury protection policy language regarding the use of the Medicare fee schedules, overriding a lower court’s ruling and handing Allstate the win. After denying the insurer’s request for review of a circuit court appellate division’s ruling in favor of medical provider Hallandale Open MRI LLC last September, the court reversed course, applying the Supreme Court’s January decision in Allstate v. Orthopedic Specialists.
Click here to read the full article (subscription required).
Filed under Legislation
Spring Break, a time where college students from all over the Country flock down to Florida, known by many as the “Spring Break Capital of the World”, looking to have some fun in the sun.
Florida has many Universities, Colleges and other institutions of higher learning that welcome students from other States to attend.
So the question is, does an out-of-state student who attends University or College in Florida for 2 or 4 years now become a resident of Florida because they have decided to live in Florida during this time? Is that out-of-state student now required to register and license their out-of-state vehicle in Florida and obtain the minimum Florida automobile insurance coverage on that vehicle which is $10,000.00 in Personal Injury Protection and $10,000.00 in Property Damage Liability?
Well yes and no.
If the out-of-state student is planning to domicile themselves in Florida then they are required to license their vehicle in Florida and obtain the minimum insurance in order to operate that vehicle on the roads and highways of the State.
However, if the student maintains their residence in another State while they are enrolled as a full-time student in an “institution of higher learning”, then they are exempt from licensing their vehicle and obtaining the minimum insurance on that vehicle during the duration of their enrollment, as long as they have complied with the licensing and insurance requirements of the State for which they are a resident. One less thing for parents to worry about when they watch their babies leave the nest for the first time.
However, what constitutes an “institution of higher learning”.
The Merriam-Webster Dictionary® defines this term as “a college or university”. But what about a trade school, vocational school or cosmetology school? The Federal Government generally defines an ”institution of higher education” as a public or nonprofit educational institution who only admits students who have a high school diploma or have a recognized equivalent certificate such as a General Educational Diploma (GED); is accredited or has pre-accreditation status; awards a Bachelor’s Degree or a 2-years Associates Degree; or, any school that provides not less than a 1-year training program beyond High School, to prepare students for gainful employment in a recognized occupation.[1]
These are inquiries that an insurance company must properly investigate in an automobile accident claim involving a nonresident student in order to determine whether they would be exempt from maintaining the minimum Florida insurance on their vehicle while in Florida or if the insurer may be required to extend that student the minimum insurance under Florida law.
So would your insured qualify for the exemption as a nonresident student?
This article is not intended to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that requires attention.
For additional information, please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com.php73-37.phx1-1.websitetestlink.com. Stephen G. Mellor is a partner in the Deerfield Beach office of Roig Lawyers who primarily focuses on out-of-state policy claims for insurance carriers.
[1] 20 U.S. Code § 1001
Filed under Personal Injury Protection (PIP)
Is an automobile insurance company required to extend Florida Personal Injury Protection (PIP) benefits to an insured who resides in another state?
Well yes and no.
An automobile insurer who sells automobile insurance policies in Florida and the nonresident insured’s state is required to extend the minimum Florida Personal Injury Protection (PIP) benefits of $10,000.00 to the insured if they are involved in a motor vehicle accident in Florida, but only if they qualify under Florida law.
To qualify, the nonresident insured’s vehicle must have been physically located in Florida for 90 nonconsecutive days out of the previous 365 days from the date of the accident. By nonconsecutive days, it means that the insured vehicle could leave Florida and re-enter and still qualify for Florida PIP benefits if the vehicle has been in Florida for longer than 90 days throughout that preceding year.
An insurer is not required to extend the $10,000.00 in Florida PIP benefits to a nonresident insured whose vehicle is not in Florida for longer than 90 nonconsecutive days out of the previous 365 days from the date of the accident.
Most if not all automobile insurance policies have an “Out-of-State Coverage” provision which will detail that insurer’s obligation to comply with a State’s minimum insurance requirements if their nonresident insured becomes subject to the insurance laws of that State. However, some insurance contracts make it the responsibility of the nonresident insured and not the insurer to purchase the required minimum Florida PIP coverage if they plan to stay in Florida for longer than 90-days.
An insurer is not required to extend additional Florida PIP benefits to a nonresident insured that enters Florida and whose insurance policy meets the States minimum PIP or No-Fault requirements.
For Example:
The New York Automobile No-Fault Law requires each insured to carry a minimum of $50,000.00 in No-Fault/ PIP benefits. Thus, if a New York resident drives their vehicle into Florida and is involved in a motor vehicle accident, then they will receive the $50,000.00 in New York PIP benefits as this is greater coverage than the minimum $10,000.00 in PIP benefits which is required under Florida law.
This article is not intended to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that requires attention.
For additional information please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com.php73-37.phx1-1.websitetestlink.com.
Filed under Personal Injury Protection (PIP)
In a 14-page ruling on Wednesday, February 15th, the 3rd District Court of Appeal upheld part of a 2012 overhaul of the state’s personal-injury protection auto insurance system that limits No-Fault (Personal Injury Protection) benefits to $2,500 for individuals who were not diagnosed with an emergency medical condition. The appeals court overturned a judge’s decision in a Miami-Dade County court citing arguments that the 2012 law overhaul was intended to help prevent fraud in the PIP insurance system, but was unconstitutional.
The ruling was in response to chiropractor Eduardo Garrido’s legal victory against Progressive American Insurance Company. Garrido was seeking a determination that the insurer should pay up to the policy limit of $10,000 in the absence of diagnosis that the patient suffered an emergency medical condition as the result of an automobile accident. He also challenged that it was unconstitutional to bar chiropractors from being able to diagnose patients with having suffered an emergency medical condition. The chiropractor treated a patient after an accident in 2013 and submitted invoices to Progressive who only paid $2,500 of the $6,075 billed. According to Progressive, there had been no determination, other than Dr. Garrido’s, a chiropractor, that the patient suffered an emergency medical condition.
Click here to view the full story.
Filed under Legislation, Personal Injury Protection (PIP)
On January 26, 2017, after months of waiting, those of us in the PIP world finally have our answer to the Allstate policy language debate. It appears that you just need to read the policy as a whole and within its context.
Does Allstate’s PIP policy provide legally sufficient notice to its insureds of its election to use the permissive Medicare fee schedules found in Florida Statute 627.736(5)(a)2 (2009) in order to limit reimbursements for medical services?
The Florida Supreme Court released its opinion on January 26, 2017 holding that Allstate’s PIP insurance policy stating that Allstate’s policy “provides legally sufficient notice of Allstate’s election to use the permissive Medicare Fee Schedule identified in section 627.736(5)(a)2 to limit reimbursements.” Allstate Ins. Co. v. Orthopedic Specialists, No. SC15-2298, at *2, (Fla. 2017).
The case before the Florida Supreme Court involved a certified decision from Florida’s Fourth District Court of Appeals, which had held that Allstate’s policy language did not provide sufficient notice to allow the insurer to apply the Medicare Fee Schedules in limiting reimbursements to bills submitted under the PIP portion of the subject policies. The Fourth District Court of Appeals had certified its decision as it provided a direct conflict with the First District Court of Appeals’ ruling in Allstate Fire & Cas. Ins. v. Stand-Up MRI of Tallahassee, P.A., 188 So. 3d 1 (Fla. 1st DCA 2015), which held that Allstate’s policy language did in fact provide sufficient notice to its insurer’s to allow the Medicare Fee Schedules to be used in limiting reimbursements to bills submitted under the PIP portion of the subject policies. The First District Court of Appeals was not the only Court in the state to opine in favor of Allstate, in fact by the time that the Florida Supreme Court held oral arguments in this matter in August of 2016, the Second and Third District Courts of Appeals had already entered rulings on the issue agreeing with the First District Court of Appeals’ opinion that Allstate had provided sufficient notice to its insureds of its intent to limit PIP reimbursement by using the permissive Medicare fee schedules found in Florida Statute 627.736(5)(a)2 (2009).
The specific portion of Allstate’s policy language which was being evaluated in Orthopedic Specialists v. Allstate Insurance Co., 177 So. 3d 19 (Fla. 4th DCA 2015), states that Allstate will make payments as follows:
“Allstate will pay to or on behalf of the injured person the following benefits:
1. Medical Expenses
Eighty percent of all reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices, and medically necessary ambulance, hospital, and nursing services.
Id. at 21. An endorsement to the policy provides:
Limits of Liability
. . . .
Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736, or any other provisions of the Florida Motor Vehicle No-Fault Law, as enacted, amended or otherwise continued in the law, including, but not limited to, all fee schedules.
Id. (emphasis and alterations omitted).” Allstate Ins. Co. v. Orthopedic Specialists, No. SC15-2298, at *3, (Fla. 2017)
The Florida Supreme Court found that “[t]he endorsement to Allstate’s policy clearly and unambiguously states that ‘[a]ny amounts payable’ for medical expense reimbursements ‘shall be subject to any and all limitations, authorized by section 627.736, . . . including . . . all fee schedules.’ When read in its context and as a whole with Allstate’s policy, the plain and obvious meaning of the endorsement is that reimbursements will be made in accordance with all of the fee schedule limitations contained within section 627.736(5)(a)2. See, e.g., Stand-Up MRI, 188 So. 3d at 3 (“Virtual Imaging requires no other magic words from Allstate’s policy and its simple notice requirement is satisfied by Allstate’s [unambiguous] language limiting ‘[a]ny amounts payable’ to the fee schedule-based limitations found in the statute.” (second alteration in original); Fla. Wellness & Rehab. v. Allstate Fire & Cas. Ins. Co., 201 So. 3d 169, 173 (Fla. 3d DCA 2016) (“The use of the phrase ‘subject to’ in the policy places the insured on notice of the limitations elected by Allstate; indeed, we cannot discern any other alternative meaning to this language.”); Allstate Indem. Co. v. Markley Chiropractic & Acupuncture, LLC, 41 Fla. L. Weekly D793, 2016 WL 1238533, at *4 (Fla. 2d DCA Mar. 30, 2016) (explaining that “Virtual Imaging did not dictate a form of notice” or require insurers to specifically state the word “Medicare”). Allstate’s policy thus places both providers and insured on notice of Allstate’s election to use the permissive Medicare fee schedules identified in section 627.736(5)(a)2. to limit reimbursements.” Allstate Ins. Co. v. Orthopedic Specialists, No. SC15-2298, at *8-9, (Fla. 2017).
Click here to read the full opinion.
Filed under Personal Injury Protection (PIP)
According to Southwest Florida Online News, a federal jury found Nesly Loute guilty of fraud after a six day trial where he and five others testified that they had conspired to operate five unlicensed chiropractic clinics and fraudulently billing auto insurers for Personal Injury Protection benefits. This ruling was the culmination of a two-year law enforcement investigation dubbed Operation Fraudulent Pain.
Loute and five other individuals who have also pleaded guilty are facing a maximum penalty of 20 years each in federal prison and must make restitution to the insurance companies they have defrauded. The unlicensed chiropractic clinics had received more that $2 million in fraudulent PIP payments.
Click here to view the full story.
Filed under Uncategorized
