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Reasonableness of charges (Fla)August 21, 2021

STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, vs M & E DIAGNOSTIC SERVICES, INC., etc., 3D20-1193 (Fla 3d DCA 2021)

When trying a boardable medical case, a really thorny issue becomes what is the value of the services billed. NY generally does not get into that issue because no-fault has a fee schedule, thereby obviating the issue on the first-party case. But how about on the third-party case where the patient solely treats on a lien? Yes, this is rare in NY save some surgery cases. But here is something of relevance, at least to me:

“Dr. Dauer attested that he has personal knowledge and expertise regarding the range and rate of charges for medical care in the relevant community, including the range and rate of charges for radiological services
provided in the area to patients by credentialed and experienced diagnostic centers and hospitals. Dr. Dauer considered the reimbursement levels an charges in the community, his own charges in the community, various federal and state medical fee schedules applicable to motor vehicles and other
insurance coverages including worker’s compensation, Medicare, HMO/PPO, and other third-party insurance carriers, and the payments and reimbursements that M & E accepts from all sources. Dr. Dauer attested to conducting numerous peer reviews and obtaining extensive personal knowledge and professional expertise regarding medical care and medical charges and medical reimbursements in the Miami-Dade and Broward
communities. Dr. Dauer opined, after reviewing the medical records for care provided to the insured, Omar Pinelo, by M & E in connection with the accident, that the contested charges were not reasonable…”

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