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  • Melisa Zwilling

11th Circuit District Court: MAO Action Against Treatment Provider Under PCOA Provision of MSP May P


A U.S. District Court for the Southern District of Florida recently held that a Medicare Advantage Organization (MAO) may bring an action against a provider for double damages under the private cause of action provision of the Medicare Secondary Payer Act (MSP). While we have seen numerous cases from Medicare Advantage Organizations against primary insurers, a claim against a treatment provider under the MSP is something that this Court had not yet considered.

In MSPA Claims 1, LLC v. Bayfront HMA Med Ctr, LLC, an enrollee of a Medicare Advantage Organization was involved in an auto accident. The enrollee received treatment at Bayfront HMA Medical Center. Bayfront, the Defendant in this matter, billed and received payment from both the enrollee’s MAO and enrollee’s no-fault insurer for the treatment provided. Plaintiff, an assignee of the MAO, filed a claim under the private cause of action provision of the MSP seeking double damages. Defendant Bayfront filed a motion to dismiss on the grounds that, among other items, the claim was not allowed because it was against a provider and because it was barred by the statute of limitations.

Unlike the Government, whose right to pursue a cause of action against a provider is explicit, the MAO’s claim was filed under the provision that allows a private party to bring an action for double damages. Defendant argued that this provision only allows a cause of action against primary plans, not providers; however, the Court disagreed.

In its analysis, the Court looked to the CMS regulations that provide MAOs with the same right to recover from a primary plan, entity, or individual that the Secretary exercises. Since the regulations provide that CMS has a right of action to recover its payment from any entity, including a beneficiary, provider, supplier, physician, attorney, state agency, or private insurer that has receive a primary payment, the MAO, having the same rights as the Secretary, also has the right to recover from a provider. In short, because the MAO can exercise the same rights as the Government to bring an action for double damages against a provider, the Court found that the private cause of action against Bayfront could proceed.

The Defendant also claimed that Plaintiff’s MSP claim was barred by the statute of limitations; however, the Court found that the Plaintiff brought the action within three years from the date that it was billed by Bayfront or had any notice that a primary payment had been made to Bayfront. As such, the action was timely and the motion to dismiss was denied with respect to the MSP claims.

This decision could bring about an entirely new wave of suits from Medicare Advantage Organizations. As always, we will keep you updated on any developments.

#USDistrictCourt #MSPA #MAO #CMS

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