Was it fraudulent billing?

CEDA HEALTH OF HIALEAH, LLC, etc., vs STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY , 3D21-11

Similar to the 2012 NY regulatory changes, the Florida law prohibits billings for services not rendered. See FSA 627.736(5)(b)1.c.. The statute, when triggered, applies to all billings. The NY regulation only seems to apply to services that were billed but not provided.

Here are the facts: ” Dr. Canizares testified that he did not have personal knowledge of the treatments, but that
based on his review of the records, it appeared that two units of Current Procedural Terminology (“CPT”) code 97110 were mistakenly billed at $90.00 each instead of one unit of CPT code 97110 at $90.00 and one unit of CPT code 97112 at $95.00. Dr. Canizares attested that two units of code 97110 were billed, although only one unit was performed on the date of treatment, and that there was no entry for code 97112 although one unit was performed on that date”

The question is whether the provider’s using 97110 twice as opposed to CPT 97110 and 97112 was the prescribed conduct that triggered the bill wipe out provsion of FSA

“We conclude the trial court improvidently granted summary judgment because there remained a genuine issue of material fact as to the manner and method in which the billing error occurred, particularly whether CEDA Health knowingly submitted the erroneous billing. State Farm did not submit any evidence to rebut Dr. Canizares’s testimony that the error was a mistake, nor did it submit any evidence demonstrating whether CEDA Health had actual knowledge of the information, acted in deliberate ignorance of the truth or falsity of the information or acted in reckless disregard of the information. Nonetheless, the trial court decided this key question of fact at the summary
judgment stage apparently concluding the negligent one-time billing error satisfied the statutory threshold. The Legislature has expressly defined the term “knowingly” with respect to insurance rates and contracts requiring that
a person “has actual knowledge of the information; acts in deliberate ignorance of the truth or falsity of the information; or acts in reckless disregard of the information.” § 627.732(10), Fla. Stat. Negligence, which is commonly defined as the failure to use reasonable care, is not the standard. As such, the trial court’s finding of negligence was not sufficient to resolve this issue of fact regarding whether CEDA Health knew of the
erroneous billing information.”

I see a $100,000 attorney fee for CEDA on this case.

Related Articles

• Understanding regulatory amendments and their impact on billing practices
• No-Fault verification requirements and compliance standards
• CPLR 3212(g) procedural framework for summary judgment
• Summary judgment motion timing rules in no-fault cases
• New York No-Fault Insurance Law