#Medicare

CMS Again Proposes to Solicit Public Comments on Section 111 Reporting Penalties

Matthew T. Dorius, Esq.

Jan 13, 2020

CMS Again Proposes to Solicit Public Comments on Section 111 Reporting Penalties

The most recent Regulatory Agenda for the Department of Health and Human Services includes another notice of a proposed rule on Civil Monetary Penalties and Medicare Secondary Payer reporting requirements. The text of the notice is set out below and is available at https://www.reginfo.gov/public/do/eAgendaViewRule?pubId=201910&RIN=0938-AT86. Section 516 of the Medicare Access and CHIP Reauthorization Act of 2015 amended the Social Security Act (the Act) by repealing certain

Reminder: Conditional Payment Letters From CMS Do Not Apply to Medicare Advantage Plans and Medicare

Matthew T. Dorius, Esq.

Jan 13, 2020

Reminder: Conditional Payment Letters From CMS Do Not Apply to Medicare Advantage Plans and Medicare

According to current data from CMS, over 36 percent of Medicare beneficiaries are enrolled in Medicare Advantage Plans and over 41 percent of Medicare beneficiaries are enrolled in Medicare Prescription Drug Plans. As such, there is a high probability when settling a case with a Medicare beneficiary that the claimant is enrolled in either a Medicare Advantage Plan or a Medicare Prescription Drug Plan. It is important to remember that conditional payment letters from CMS do

Sixth Circuit Remands Case to District Court for Further Consideration Regarding Standing

Melisa Zwilling

Sep 19, 2018

Sixth Circuit Remands Case to District Court for Further Consideration Regarding Standing

Duncan v. Liberty Mutual Insurance Company, arises following a motor vehicle accident the late David Duncan was involved in on January 11, 2013. At the relevant time, Duncan was a Medicare beneficiary, and Liberty Mutual was Duncan’s automobile no-fault insurer. Following the accident, Duncan brought a claim against Liberty Mutual for payment of his medical bills. When Duncan died in 2014, his estate continued to pursue the claim and, eventually, filed an action in Michiga

Medicare Compliance and the Opioid Epidemic - How Policy Changes May Impact Future Treatment

Melisa Zwilling

Aug 16, 2018

Medicare Compliance and the Opioid Epidemic - How Policy Changes May Impact Future Treatment

The opioid epidemic has become the subject of much conversation over the last few years following increases in substance abuse and deaths resulting from the improper use of opioid medications. The Department of Health and Human Services and the Centers for Medicare and Medicaid Services are actively working to combat the epidemic through a number of strategies, some of which could greatly impact the standard of care and appropriate treatment recommendations for certain condi

U.S. District Court Dismisses Action Against CMS Due to Lack of Subject-Matter Jurisdiction

Melisa Zwilling

Jul 31, 2018

U.S. District Court Dismisses Action Against CMS Due to Lack of Subject-Matter Jurisdiction

In Country Mutual Insurance Company v. Decker, 2018 U.S. Dist. LEXIS 115281 (July 11, 2018), the United States District Court for the Western District of Kentucky determined that the United States Department of Health and Human Services for Medicare and Medicaid Services (“CMS”) must be dismissed from an action filed by Country Mutual Insurance Company (“Country Mutual”), as CMS had not waived its right to sovereign immunity and the other parties to the matter had not properl

Law Firm Reaches Agreement with the United States Department of Justice Regarding the Firm’s Failure

Melisa Zwilling

Jul 16, 2018

Law Firm Reaches Agreement with the United States Department of Justice Regarding the Firm’s Failure

The U.S. Attorney’s Office for the Eastern District of Philadelphia issued a press release regarding a settlement agreement with a Philadelphia personal injury law firm. The agreement followed an investigation into allegations that the firm failed to reimburse the federal government for Medicare conditional payments issued on behalf of their clients’ medical care. Under the agreement, the firm’s principal is required to make a $28,000 lump sum payment and to establish a compl

U.S. District Court Holds that a Plaintiff Must Exhaust Administrative Proceedings Prior to Judicial

Melisa Zwilling

Mar 23, 2018

U.S. District Court Holds that a Plaintiff Must Exhaust Administrative Proceedings Prior to Judicial

A U.S. District Court affirmed that a plaintiff must exhaust the administrative appeals process before seeking a declaratory judgment that Medicare is not entitled to recover conditional payment claims. In Weiss v. Price, the Plaintiff filed a medical malpractice suit, following the death of her husband, alleging two claims: (i) a wrongful death claim, in her individual capacity, and (ii) a survivorship claim, on behalf of the Estate. The state court judge allocated all settl

UPDATE: Eleventh Circuit Court of Appeals Upholds District Court Decision Giving Medicare Advantage

Melisa Zwilling

Feb 27, 2018

UPDATE: Eleventh Circuit Court of Appeals Upholds District Court Decision Giving Medicare Advantage

As you will recall, in August 2016, the United States Court of Appeals for the Eleventh Circuit, following the lead of the Third Circuit’s decision in In re Avandia, affirmed the decision of the lower court in Humana Med. Plan v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016). In an opinion written by Judge Black, the Eleventh Circuit determined that Humana, as a Medicare Advantage Organization (MAO), had a private cause of action under the Medicare Secondary Payer Act

State Court Refuses to Reduce Plaintiff's Economic Damages Award Due to Medicare's Subrogati

Melisa Zwilling

Sep 26, 2017

State Court Refuses to Reduce Plaintiff's Economic Damages Award Due to Medicare's Subrogati

William Ashmore presented to Hartford Hospital for a non-emergency, planned procedure. It was during his hospital stay that he passed away as a result of the alleged negligence of the employees of the hospital. Suit was brought against the hospital by Mr. Ashmore’s estate and $75,000 in economic damages were awarded following a jury trial. The damages represented the amount billed to William Ashmore by Hartford Hospital (Defendant) for the hospital stay during which he passe

CMS Releases New Re-Review Option for WCMSAs

Melisa Zwilling

Jul 19, 2017

CMS Releases New Re-Review Option for WCMSAs

On July 10, 2017, CMS issued an updated Workers’ Compensation Medicare Set-aside Portal (WCMSAP) User Guide which includes an expanded re-review process. The re-review process now allows for an Amended Review of cases where projected care has changed so much that a previously approved MSA amount will change by at least 10% or $10,000 (whichever is greater). The new proposed MSA amount can be greater or less than the previously approved MSA amount as long as the difference is

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