At the Dolman Law Group, we take great pride in making sure that every “Benefits Exhausted” claim by an insurance company is completely true. We do this by personally reviewing all payments to all other medical providers, other than yours on a given Personal Injury Protection (“PIP”) case. For more information on Benefits Exhaustion see:
As the other article indicates “[i]n order for an insurance company to truly exhaust benefits they could not have made any “gratuitous payments”. A gratuitous payment is, essentially, any payment made by an insurance company on a claim that should not have been paid, or paid over the amount that is “reasonable”. Meaning scenarios such as an insurance company paying a bill that was received in excess of 35 days past the date of service would be gratuitous. Another common scenario is when a certain CPT code is paid in excess of the fee schedule for that particular year. Even if the amount is small (a few dollars) it is actionable. “
Recently it has come to our attention that certain insurance companies are paying what is known as the “Limiting Charge” for MRI codes. Specifically, a very common code, CPT Code 72148 (MRI of the Lumbar Spine without Dye) is being paid over the Medicare Fee Schedule. So what is the difference between the Medicare Fee Schedule and the “Limiting Charge?”
The argument for the Defense, in this scenario, is that the statute is vague when it describes what the actual “fee schedule of Medicare Part B”. Therefore they are airing on the side of caution when it comes to choosing the higher number (the limiting charge) when paying for the MRI codes. At Dolman Law Group we greatly disagree with their position. The schedule of maximum charges (the fee schedule) is described in Florida Statute 627.736(5)(a) as:
(5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
(a) A physician, hospital, clinic, or other person or institution lawfully rendering treatment to an injured person for a bodily injury covered by personal injury protection insurance may charge the insurer and injured party only a reasonable amount pursuant to this section for the services and supplies rendered, and the insurer providing such coverage may pay for such charges directly to such person or institution lawfully rendering such treatment if the insured receiving such treatment or his or her guardian has countersigned the properly completed invoice, bill, or claim form approved by the office upon which such charges are to be paid for as having actually been rendered, to the best knowledge of the insured or his or her guardian. However, such a charge may not exceed the amount the person or institution customarily charges for like services or supplies. In determining whether a charge for a particular service, treatment, or otherwise is reasonable, consideration may be given to evidence of usual and customary charges and payments accepted by the provider involved in the dispute, reimbursement levels in the community and various federal and state medical fee schedules applicable to motor vehicle and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service, treatment, or supply.
1. The insurer may limit reimbursement to 80 percent of the following schedule of maximum charges:
. . . f. For all other medical services, supplies, and care, 200 percent of the allowable amount under:
(I) The participating physicians fee schedule of Medicare Part B, except as provided in sub-sub-subparagraphs (II) and (III).
The keyword in the above is the word “participating”. Participating means that the physician or provider is choosing to accept Medicare amounts. This is in stark contrast to the term “non-participating”. The limiting charge is a payment methodology for those who are non-participating. The Centers for Medicare Services describes the limiting charge as:
“In Original Medicare, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept the assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.”
Essentially the easier way to do the math is that it is 115% of 95% of the Medicare Part B rate. Hence, if the limiting charge is a math equation based on the “fee schedule”, it in-and-of–itself cannot be the “participating fee schedule” mentioned in the statute.
Therefore, when it comes to CPT Code 72148, 200% of Medicare Part B fee schedule is $1066.28. The insurance company then pays 80% of that number to make a payment to the MRI facility of $853.02. When the insurance company uses the “limiting charge” the approved amount is $1169.92 in which they pay 80%, which turns out to be $935.94. So why is this important?
Because the insurance company paid the MRI facility $78.92 over what they should have paid them, they made a gratuitous payment. Meaning that $78.92 is still remaining in PIP benefits. That amount was owed to you.
For the above reasons, it is very important not to take an insurance company’s word as gold. At Dolman Law Group we do not take the insurance company for their word like other firms. When Dolman Law Group tells you benefits are exhausted, you can know truly that they are. If an insurance company is telling you that benefits are exhausted, continue to bill the insurance company, contact Dolman Law Group at 727-451-6900 or and let us take a look at the file to ensure they are telling you the truth.
Dolman Law Group
800 North Belcher Road
Clearwater, FL 33765