Coastal Wellness Ctrs., Inc. v. Progressive Am. Ins. Co.
Coastal Wellness Ctrs., Inc. v. Progressive Am. Ins. Co.
Opinion of the Court
THIS CAUSE is before the Court on Defendant Progressive American Insurance Company's Motion to Dismiss [DE 34], filed herein on March 12, 2018. The Court has carefully considered the Motion [DE 34], and is otherwise fully advised in the premises.
I. Background
This is an action asserting class action claims for declaratory relief, injunctive relief, and compensatory damages relief pursuant to Federal Rules of Civil Procedure 23(a), (b)(2), and/or (b)(3). [DE 1] at ¶ 1.
The action arises out of a November 21, 2014 auto accident involving Janeece Farley, who was insured under an automobile insurance policy providing personal injury protection ("PIP") benefits issued by Defendant, Progressive American Insurance Company ("Progressive"). Following the accident, Farley sought chiropractic treatment for her bodily injuries from Plaintiff, Coastal Wellness Centers, Inc.
On or about November 21, 2014, Farley executed an Assignment of Insurance Benefits, Release & Demand, assigning all of her benefits under the subject policy to Coastal. The purpose of the assignment was to authorize Coastal to bill Progressive directly for the medical services provided to Farley, and to require Progressive to pay Coastal directly at its home office. As the assignee of Farley's PIP benefits, Coastal billed Progressive for medical services Plaintiff provided to Farley. Accordingly, Plaintiff Coastal asserts standing to sue based on the Assignment of Benefits received from Farley.
Included in the treatment Plaintiff provided to Farley were two (2) chiropractic manipulative treatment services billed under CPT code 98940. Plaintiff alleges that, while the correct reimbursement rate for each unit of CPT code 98941 was $46.51, Progressive only paid Plaintiff $45.58 for *1219each, thus underpaying Plaintiff a total of about $2.
In its three-count Complaint, Plaintiff claims as follows: Count I-Declaratory Judgment; Count II-Injunctive Relief; and Count III-Breach of Contract for Unpaid PIP Benefits.
Defendant moved to dismiss the Complaint for failure to state a claim pursuant to Fed. R. Civ. P 12(b)(6). [DE 34].
II. Standard of Review
Rule 8(a)(2) requires "a short and plain statement of the claim showing that the pleader is entitled to relief," in order to "give the defendant fair notice of what the ... claim is and the grounds upon which it rests." Conley v. Gibson ,
However, the court need not take allegations as true if they are merely "threadbare recitals of a cause of action's elements, supported by mere conclusory statements." Iqbal ,
"A court's review on a motion to dismiss is 'limited to the four corners of the complaint.' " Wilchombe v. TeeVee Toons, Inc. ,
III. Discussion
This case presents a question of interpretation of the Florida No-Fault ("PIP") Statute,
*1220Plaintiff does not contest whether Defendant's automobile insurance policy properly elected the "schedule of maximum charges." The parties agree that Progressive is entitled to limit reimbursement for medical expenses based on the "schedule of maximum charges" contained in Section (5)(a) of the PIP Statute. See
The "schedule of maximum charges" limits payment for the chiropractic services rendered by Plaintiff to "200 percent of the allowable amount under" the "participating physicians fee schedule of Medicare Part B." See
The reimbursement value for services under the PPFS-MPB are calculated by multiplying (1) the relative value of a service; (2) the conversion factor for the particular year; and (3) the geographic adjustment factor applicable to the locality in which the service was provided. See 42 U.S.C. § 1395w-4(b)(1). Therefore, using simple arithmetic (addition and multiplication), the reimbursement value for any service, in any part of the United States, for any given year can be easily ascertained by the Defendant using the Medicare Part B Physicians Fee Schedule. The tables of values for the cost factors are published each year in the annual Medicare Physicians Fee Schedule Final Rule and are readily available and easily accessible on the Centers for Medicare and Medicaid ("CMS") website.
The instant dispute arises from Progressive's application of the PPFS-MPB in effect in 2012-2014. During that timeframe, a 2% reduction was imposed on chiropractic services paid for by Medicare in order to recoup costs for a study/demonstration conducted by Brandeis University to evaluate the feasibility of expanding Medicare coverage for certain chiropractic services. See 74 Federal Register 61926-61928. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (hereinafter "MMA") required that the study be "budget neutral;" therefore, the CMS Office of the Actuary ("OACT") established a plan to recoup the outstanding $50 million apportioned to CMS to fund the study by reducing the payment by Medicare for chiropractic fee codes 98940, 98941 and 98942 by two percent (2%) commencing in calendar year 2010 through calendar year 2014.
The Department of Health and Human Services ("HHS") made it clear that the 2% reduction was only to be applied to Medicare claims:
Consistent with the proposed rule, for this final rule with comment period, we are reflecting this reduction only in the payment files used by the Medicare contractors *1221to process Medicare claims rather than through adjusting the RVUs. Avoiding an adjustment to the RVUs would preserve the integrity of the PFS, particularly since many private payers also base payment on the RVUs.
Plaintiff asserts that the Defendant misinterpreted what is the Medicare Part B Physicians Schedule and misapplied the CMS Payment Files instead, which resulted in improper, unauthorized reductions by 2% for each unit of a chiropractic manipulation. The Court agrees. Notwithstanding that no provisions of
The Court rejects Defendant's argument that it was permitted to use the 2% fee reduction because those values were calculated into the CMS payment files. Regardless of whether it was easier for a private payer to use those values rather than calculate the formula once a year, such reduction is contradicted by the plain language of § 627.736(5)(a) 1, which clearly allows an insurer to limit reimbursement to medical care to the treating chiropractor to "200 percent of the allowable amount under" the "participating physicians fee schedule of Medicare Part B." See
Based upon the foregoing, Defendant could not take advantage of the 2% reduction which was incorporated into the CMS Payment Files to allow Medicare to recoup the cost of a study in order to reduce its payments to Plaintiff. Defendant's motion to dismiss for failure to allege a cognizable claim for declaratory relief, injunctive relief, or damages shall be denied.
Defendant also argues in its Motion that injunctive relief is unnecessary because the chiropractic demonstration ended in 2014, the CMS Payment Files no longer reflect a 2% reduction, and therefore Plaintiff cannot allege that Defendant continues to currently apply the 2% reduction. However, while the 2% reduction was only in effect from 2010 to 2014, the statute of limitations has not run on all underpaid claims arising from Defendant's practice at the time, and Plaintiff adequately pleads in the Complaint that Defendant continues to improperly reduce the payments of those claims or refuses to pay the *1222proper amounts. Accordingly, the Court declines to dismiss the claim for injunctive relief at this time.
Defendant also contends that Plaintiff's counts for declaratory and injunctive relief should be dismissed because Plaintiff has an adequate remedy at law. The Court rejects Defendant's argument that Plaintiff cannot assert a claim for declaratory relief when an adequate alternative remedy exists at law. "Such a position is in direct contravention of Rule 57 of the Federal Rules of Civil Procedure" which provides that "[t]he existence of another adequate remedy does not preclude a declaratory judgment that is otherwise appropriate." DWF Mgmt., LLC v. Starr Indem. & Liab. Co. , No. 16-CV-61238-KMM,
Finally, Defendant claims that Plaintiff has failed to allege class-wide compliance with the PIP statute's pre-suit notice requirement. See
IV. CONCLUSION
Based upon the foregoing, it is hereby ORDERED AND ADJUDGED as follows:
1. Defendant's Motion to Dismiss [DE 34] is DENIED.
*12232. Defendant shall file an answer within fourteen (14) days of the date of this Order.
DONE AND ORDERED in Chambers in Fort Lauderdale, Broward County, Florida this 3rd day of April, 2018.
All facts set forth in the background are according to the allegations of the Complaint [DE 1], which the Court assumes as true for purposes of this Motion.
Formerly subsection 627.736(5)(a)(1) under the 2008 version of the PIP statute.
Formerly subsection 627.736(5)(a)(2) under the 2008 version of the PIP statute.
The Court may take judicial notice of government publications and website materials. See, e.g., Abdus-Sabur v. Hope Village, Inc. ,
Reference
- Full Case Name
- COASTAL WELLNESS CENTERS, INC., a Florida corporation, a/a/o Janeece Farley, on behalf of itself and all others similarly situated v. PROGRESSIVE AMERICAN INSURANCE COMPANY, Tower Health Center, Inc., a Florida corporation, a/a/o Alston Lawrence and Coastal Care Center, Inc., a Florida corporation, a/a/o Jinnicka Delhomme on behalf of themselves and all others similarly situated v. Progressive Select Insurance Company
- Cited By
- 9 cases
- Status
- Published