#MedicareSecondaryPayer

CMS to Host Webinar to Discuss CRC ORM Recovery Issues

Matthew T. Dorius, Esq.

Jan 8, 2020

CMS to Host Webinar to Discuss CRC ORM Recovery Issues

CMS recently announced that they are hosting a webinar to discuss issues with CRC’s recovery of conditional payment claims in cases involving ORM. The webinar is scheduled for Tuesday, January 14, 2020, at 1:00 Eastern Time. CMS plans to allow questions and provide answers following the presentation. In order to view and listen to the presentation, participants will need to use the webinar URL and conference call information below. CMS requests that participants plan to jo

District Court Affirms Medicare Advantage Organization’s Right to Sue Primary Plans Pursuant to the

Melisa Zwilling

Apr 6, 2018

District Court Affirms Medicare Advantage Organization’s Right to Sue Primary Plans Pursuant to the

A U.S. District Court followed the trend of permitting a Medicare Advantage Organization (“MAO”) to sue pursuant to the Medicare Secondary Payer Act’s (“MSPA”) Private Cause of Action (“PCOA”) provision. In Aetna Life Ins. Co. v. Guerrera, Aetna, a MAO, paid medical expenses on behalf of a Medicare beneficiary after he sustained personal injuries at a grocery store. After Aetna notified the defendant-grocery store of its lien, the grocery store settled and issued payment to t

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

New Developments In The Case Of CIGA v. Burwell

Melisa Zwilling

May 23, 2017

New Developments In The Case Of CIGA v. Burwell

In January 2017, we posted an article concerning a recent case, Cali. Ins. Guar. Ass’n v. Burwell, No. 2:15-cv-01113-ODW (FFMx), 2017 U.S. Dist. Ct. LEXIS 1681. As you may recall, the Defendant (CMS) paid medical benefits on the behalf of three individuals who were also covered under workers’ compensations policies administered by the Plaintiff (California Insurance Guaranty Association (CIGA)). CMS sought reimbursement from CIGA for the payments issued and CIGA argued that t

U.S. District Court Upholds Dismissal of Claim Brought Under the Private Cause of Action Provision o

Melisa Zwilling

Apr 27, 2017

U.S. District Court Upholds Dismissal of Claim Brought Under the Private Cause of Action Provision o

In the present case, Claims v. Co. V., No. 16-20338-CIV-LENARD/GOODMAN, 2017 U.S. Dist. Ct. LEXIS 43755, the Plaintiff (MSPA Claims 1, LLC) alleges that the Defendant (Covington Specialty Insurance Company) violated the Medicare Secondary Payer Act (MSP) by failing to reimburse payments made by a beneficiary’s Medicare Advantage Plan (MAP) provider for medical expenses incurred related to an accident for which Defendant was the primary payer. The Defendant insurer provided a

ALERT: District Court Finds CMS Erred in Requiring Carrier to Reimburse Entire Provider Charge Rathe

Melisa Zwilling

Jan 26, 2017

ALERT: District Court Finds CMS Erred in Requiring Carrier to Reimburse Entire Provider Charge Rathe

It is a familiar story for many insurance carriers and self-insured employers—Medicare has asserted a number of conditional payment claims which they indicate are related to an accident-related injury. Although the majority of the diagnosis codes associated with the charges are clearly unrelated to the injuries at issue, one code is related. Because of that one code, CMS assumes the entire charge is related to the accident and requests reimbursement for everything. In order

District Court Grants Motion to Dismiss After U.S. Argues that Court Lacks Jurisdiction Over Medicar

Melisa Zwilling

Nov 15, 2016

District Court Grants Motion to Dismiss After U.S. Argues that Court Lacks Jurisdiction Over Medicar

In Cheryl Nelson & Geico Gen. Ins. Co. v. Medi-Cal., No. 1:16-cv-01328-LJO-BAM, 2016 U.S. Dist. Ct. LEXIS 153596 (E.D. Cal., November 4, 2016), the Plaintiffs (Geico General Insurance Company and Cheryl Nelson) brought an action for an interpleader of funds. The Plaintiffs intended on resolving competing claims by twelve entities against a $100,000.00 motor vehicle accident insurance settlement which was to be paid to the injured party. Plaintiffs alleged that they were unabl

Alert! Eleventh Circuit: Contractual Obligation Sufficient to Establish “Demonstrated Responsibility

Melisa Zwilling

Sep 21, 2016

Alert! Eleventh Circuit: Contractual Obligation Sufficient to Establish “Demonstrated Responsibility

What qualifies as a “demonstrated responsibility” sufficient to proceed under the private cause of action provision of the Medicare Secondary Payer Act has been a recent hot topic of discussion. Following the Eleventh Circuit’s decision in Glover v. Liggett Group, several courts found that a contractual relationship alone would not suffice. Recently, however, the Eleventh Circuit Court of Appeals issued a decision that will change the way that we think about this requirement

US District Court: Plaintiff Responsible for Full Amount of Formal Demand

Melisa Zwilling

Mar 23, 2016

US District Court: Plaintiff Responsible for Full Amount of Formal Demand

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

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