Suit Using the MSPA Private Cause of Action Requires a Conditional Payment by Medicare

In this case, the plaintiff attempted to bring suit under the Medicare Secondary Payer Act (MSPA) and sought double damages under the MSPA’s private cause of action. The plaintiff argued that defendant benefit plan attempted to pay for dialysis treatment at a lower rate when the patient was a Medicare beneficiary due to End-Stage Renal Disease, in violation of the MSPA and ERISA. DaVita, Inc. v. Marietta Memorial Hospital Employee Health Benefit Plan, 2020 U.S. App. LEXIS 32398 (6th Cir. October 14, 2020).

Defendant argued that suit under the MSPA’s private cause of action was inappropriate because Medicare had not made conditional payments for any of the dialysis treatments. The court agreed with the defendant, holding that the MSPA’s private cause of action and double damages is not available when Medicare has not made a conditional payment.