Progressive American Insurance Company v. Head to Toe Posture Rehab, LLC a/a/o Alix Louis

Summary

The Florida Fourth District Court of Appeal held that section 627.736(5)(a)3., Florida Statutes (2014), permits an insurer to use Medicare’s Multiple Procedure Payment Reduction methodology to limit PIP reimbursement for therapy services lawfully provided by a licensed chiropractor. The court reversed summary judgment for the healthcare provider and remanded with instructions to enter summary judgment for the insurer.

Holdings

1. Section 627.736(5)(a)3., Florida Statutes (2014), authorizes an insurer using the MPPR methodology to limit PIP reimbursement for therapy services lawfully provided by a licensed chiropractor, even when Medicare would not reimburse a chiropractor for those same services.
2. The policy permitted use of the MPPR methodology to limit PIP reimbursement because it provided sufficient notice of the insurer's intent to use Medicare coding policies and payment methodologies, including applicable modifiers.

Questions Presented

1. Whether section 627.736(5)(a)3., Florida Statutes (2014), permits an insurer to use Medicare's Multiple Procedure Payment Reduction methodology to limit PIP reimbursement for therapy services lawfully provided by a licensed chiropractor when Medicare itself would not reimburse a chiropractor for those services.
2. Whether the insurance policy provided sufficient notice that the insurer could use Medicare coding policies and payment methodologies, including the Multiple Procedure Payment Reduction methodology, to calculate PIP reimbursement.

Disposition

reversed_and_remanded