In Sexton v. Medicare, 2016 U.S. Dist. LEXIS 89818, Medicare made conditional payments for Plaintiff’s treatment after Plaintiff was injured in a motor vehicle accident. After the conditional payments were made, Medicare issued a conditional payment letter to Plaintiff notifying him that Medicare had paid $678.80 for treatment of his accident-related injuries and that he may be required to reimburse Medicare for medical expenses related to his liability claim in the future. T

In Anderson v. Burwell, 2016 U.S. Dist. LEXIS 26633 (March 3, 2016), a case arising out of the United States District Court for the Eastern District of Michigan, Southern Division, the Court upheld the Administrative Law Judge’s decision requiring Plaintiff to reimburse Medicare for the full amount of the formal demand, rather than the amount of the prior Conditional Payment Letter (CPL). After Barbara Anderson passed away on September 20, 2006, Roland Anderson (Plaintiff), a

On January 20, 2016, the US District Court for the Western District of New York issued an order dismissing the claims of Kent Takemoto against numerous defendants 2016 U.S. Dist. LEXIS 6468. In his complaint, Takemoto alleged that countless insurer, self-insurer and TPA defendants violated the Medicare Secondary Payer Act by “knowingly and improperly” avoiding their “obligation to reimburse the United States for payments made to Medicare beneficiaries.” The court found tha

It’s here! The ability to obtain a Final Conditional Payment Amount prior to settlement has gone live. As we discussed in November, as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP was to be modified to include a new functionality allowing authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that a final conditional payment amount is provided. CMS’ Decembe

In the most recent decision in a series of cases involving a 2009 incident at a condominium, a Florida Court of Appeal finds that the lower court erred in finding subject matter jurisdiction when determining the recovery rights of a Medicare Advantage Plan. Ms. Reale, the plaintiff in the present case, was injured in 2009 at a condominium insured by Western Heritage. Humana, a Medicare Advantage Plan, paid for treatment related to that injury. Humana originally pursued recove

In Iowa Supreme Court Atty. Disciplinary Bd. v. Silich, No. 15-1227, 2015 Iowa Sup. LEXIS 97 (Iowa, December 4, 2015), a complaint was brought by the state disciplinary board against an Iowa plaintiff’s attorney, Paul Silich, after it took him thirty-three months to resolve the Medicare lien in his clients’ liability case. Silich represented the conservator for the son of the deceased injured party as well as Clinton National Bank, the administrator of the injured party’s est

In October, a new contractor, the Commercial Repayment Center (CRC), began handling conditional payment claim recovery for claims in which CMS is pursuing recover directly from the primary payer. As you might imagine and may have already experienced, the new contractor has brought many changes to the conditional payment claim recovery process. One of those changes concerns the authorization required for the CRC to provide information to an applicable plan’s agent and has been

As we previously reported, beginning October 5, 2015, the Commercial Repayment Center (CRC) will handle the recovery of conditional payment claims when CMS is pursuing reimbursement directly from the primary payer. The Benefits Coordination and Recovery Center (BCRC) will still handle the recovery process when CMS is pursuing reimbursement from the beneficiary. CMS has indicated that the CRC may pursue recovery from the RRE when ORM has been reported under Section 111 or w

On September 17, 2015, CMS held a webinar to discuss the new role of the Commercial Repayment Center (CRC) in the NGHP recovery process. Beginning October 5, 2015, the CRC will handle the recovery of conditional payment claims when Medicare is pursuing reimbursement directly from the primary payer. CMS indicated in the webinar that the CRC will primarily pursue recovery from the primary payer in cases in which ORM has been reported under Section 111 or the primary payer has

Below are just a few of our recent results! Our goal is to exceed our clients expectations and deliver results. We work tirelessly to do that in every case. •Filed for reconsideration of a $438,305 MSA requested by CMS. We submitted documentation and substantive arguments in support of our request. CMS issued a new approval for $284,507. Client Savings = $153,798 • File was referred to us for a second opinion after MSA allocation from another vendor was more than $80,000.