Thought Leadership

The instant suit involved a plaintiff’s contention that a physician’s assistant reduction in a bill balance was improper. The bill in question was for date of service May 26, 2016, and involved CPT code 99204. The defendant had paid $225.43 by applying the physician assistant’s payment methodology to the 200% of Medicare fee schedule amount. The plaintiff alleged that this was improper and, therefore, an additional $40.59 was due and owing. The court previously heard the plaintiff’s argument as to that issue and ruled in favor of the plaintiff. 

However, the defendant had also pled a demand letter defense, which was outstanding. The court ended up ruling in favor of the defendant on the demand letter issue because the plaintiff’s demand letter included a ledger showing a zero dollar balance owed. The court found that the $40.59 alleged to be owed was never alleged in its pre-suit demand letter. The court further analyzed the ledger, which stated: “Maria has 1 claims (SIC) totaling $662.12 with an outstanding balance of $0.00.” 

The court then analyzed the purpose of Fla. Stat. 627.736(10) and found that the purpose of the pre-suit demand letter provision of the statute is to give the insurer notice of what its potential liability would be and to give the insurer one last chance to cure the claim at issue. The court concluded that in this case, the medical provider clearly notified the insurer that there was no money owed by submitting a ledger attached to the demand letter showing a $0 balance. The court went on to state: “Any reasonable person that receives a bill or statement stating there is no money owed would not make a payment on that bill or statement.” When analyzing the Statute, the court found that Section 627.736(4)(b) provides that no payment shall be overdue, notwithstanding written notice, “when the insurer has reasonable proof to establish that the insurer is not responsible for payment,” which in the instant suit is surely the case when the provider does not know what “payment” is due. 

The court then analyzed other DCA decisions on the issue and cited MRI Associates of America, LLC v. State Farm Fire & Casualty Co., 61 So. 3d 462, 465 (Fla. 4th DCA 2011) in which the 4th DCA held that the pre-suit demand letter of section 627.736(10) requires precision in a demand letter by the requirement that it must include an itemized statement specifying each exact amount owed. The court also analyzed a recent 3rd DCA decision in Rivera v. State Farm Mut. Auto. Ins. Co., 317 So. 3d 197, 204-205 (Fla. 3d DCA 2021), in which the court also held that section 627.736(10) requires precision, which includes the provider putting the insurer on notice of “the exact amount for which it will be sued if the insurer does not pay the claim.” Finally, the court analyzed other County Court decisions that have ruled that when a demand letter states that $0.00 is owed, it fails to comply with Fla. Stat. 627.736(10). Florida Injury Longwood, LLC a/a/o Aaron Clements v. USAA Case. Ins. Co., 25 Fla. L. Weekly Supp. 970b (Fla. Cty. Ct. 9th Cir. 2017); Injury Centers of St. Pete., Inc. a/a/o Stetson Estes v. Garrison Property and Cas. Ins. Co., 25 Fla. L. Weekly Supp. 192a (Fla. Cty. Ct. 13th Cir. 2017). 

This ruling is significant because it further codifies the requirements of Fla. Stat. 627.736(10) that a demand letter must identify the exact amount being demanded. As such, each and every single PIP suit should have an affirmative defense for failure to comply with Fla. Stat. 627.736(10) due to the ever-evolving nature of the case law regarding demand letters. Also of note is how the plaintiff technically prevailed on its improper reduction argument, but because of the demand letter issue, the carrier won the day.
 

_{Case Law Alerts, 1st Quarter, January 2023 is prepared by Marshall Dennehey to provide information on recent developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. Copyright © 2032 Marshall Dennehey, all rights reserved. This article may not be reprinted without the express written permission of our firm.}