Key Takeaway
Explore two avenues of reimbursement in no-fault insurance: fee schedules vs. reasonable and customary charges. Florida court ruling on expert testimony methodology.
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, vs ALL X-RAY DIAGNOSTIC SERVICES, CORP., A/A/O PEDRO RIOS, . 3D21-0063 (Fla 3d DCA 2022)
There are two avenues of reimbursement – the fee schedule and R and C. The prior precedent used to be simply that you chose one and that is it. The Courts have held that you can play with both mechanisms of reimbursement, of course using as an expert to achieve the more advantageous result for the carrier
“However, even if Dr. Dauer’s affidavit did in fact rely entirely on the Medicare Part B fee schedules as the basis for reasonableness (which it did not), the affidavit was not “pure opinion” evidence because it resulted from the application of reliable principles and methods to the facts of the case. The affidavit addresses Dr. Dauer’s qualifications as a medical doctor, his experience with reimbursement levels in the community, the factors in section 627.736(5)(a)1., as well as the underlying data Dr. Dauer reviewed.
The affidavit explains which information influenced Dr. Dauer’s opinion regarding reasonableness and how, and also individually addresses each of the Daubert factors in relation to the specific methodology used. Finally, the affidavit explains the rationale behind the methodology used and why it was
reliable, and also explains why Dr. Dauer believed his conclusions were consistent with the PIP statute and prevailing practices in the industry.”
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What is New York's no-fault insurance system?
New York's no-fault insurance system requires all drivers to carry Personal Injury Protection (PIP) coverage. This pays for medical expenses and lost wages regardless of who caused the accident, up to policy limits. However, you can only sue for additional damages if you meet the 'serious injury' threshold.
