Merkle v. Health Options

REIMBURSEMENT

Merkle v. Health Options, Inc., No. 4D05-4552 (Fla. App. Ct.
Oct. 18, 2006)

A
physician whose professional association provided emergency orthopedic services
to HMO patients brought a class action suit on behalf of nonparticipating providers
seeking declaratory relief under Florida statutory law as well as damages for
unjust enrichment. The crux of the physician’s complaint was whether Florida
Statute §641.513(5), which provides the method of payment for nonparticipating
providers, authorizes an implied private right of action. The HMO argued that
it did not, and therefore the HMO’s payment of 120% of Medicare reimbursement
rates, as opposed to the "usual and customary" charges obligated by
statute, was not actionable. The District Court of Appeal of Florida disagreed,
and held that the physician could bring a private suit under the statute. Otherwise,
the court noted, the statute would have little "useful purpose." The
court further ruled that the physician’s claims for unjust enrichment were improperly
dismissed by the trial court, as the physician had sufficiently alleged facts
indicating that his treatment of HMO subscribers at the lower reimbursement rate
conferred a benefit upon the HMO. The case was remanded to the trial court for
deliberation on the merits of the physician’s claims.