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Louisiana Appellate Court Rules CMS Approval of MSA Was a Suspensive Condition that Suspended Obligation to Fund the MSA Until CMS Approval

Rafael Gonzalez, Esq. President, Flagship Services Group

On May 2, 2018, the Third Circuit Court of Appeal of Louisiana published its opinion on Mary Ortega v. Cantu Services, Inc., concluding that the settlement of the workers compensation claim at hand was conditioned on CMS approval of a Medicare Set-Aside. Because the settlement agreement did not include specific dates or amount of time within which such CMS approval should be obtained, employer/carrier were not required to pay the settlement funds prior to CMS approval of the MSA, as nonpayment was the result of conditions over which the employer/carrier had no control.

This case brings to light the never-ending questions of whether parties should submit their MSAs to CMS for approval, and whether to settle a Medicare file with an MSA continent or dependent upon CMS approval of the MSA. Time and time again CMS has indicated such submission is not mandatory, but completely voluntary. But at the same time, CMS is quick to remind litigants that without such approval, CMS is not bound by any agreement, stipulation, or settlement of the parties. If the parties are going to make approval of the MSA by CMS a centerpiece of their settlement, and are going to hold completion of settlement until such time as CMS approves the MSA, as based on this case and the many others similarly decided by courts throughout the country over the years, it is important to be as specific as possible.

 

Facts of the case and procedural history

This workers’ compensation case arises out of a work injury that Mary Ortega (Ortega), sustained while she was employed by Cantu Services, Inc. (Cantu). Ms. Ortega filed a Disputed Claim for Compensation on June 27, 2014. The parties reached a settlement agreement in 2016, for $120,000, with counsel for Cantu and its insurer Liberty Mutual agreeing to submit to the Centers for Medicare and Medicaid Services (CMS) a Medicare set aside (MSA) in the amount of $56,049. If CMS did not did not approve the requested MSA, Cantu and Liberty Mutual agreed to fund the MSA as directed by CMS and then adjust the amount to be paid in benefits accordingly, so that the total of the settlement still amounts to $120,000.

The agreement was judicially approved and recited in open court on September 1, 2016. The agreement was explained on the record by counsel for Cantu and its insurer, Liberty Mutual Insurance Company. The Workers Compensation Judge (WCJ), Judge Braddock, then approved the compromise and stayed the docket numbers until he heard from the parties in the future, after CMS approved the MSA, to then close out the cases.

On December 22, 2016, Ms. Ortega filed a Motion and Order to Amend, adding penalties and attorney fees for Appellees’ failure to pay the settlement within thirty days after the recitation of the agreement in open court. Ms. Ortega also filed a Motion to Enforce Settlement and for penalties and attorney fees, which was heard on June 1, 2017. The court considered the minutes from the September 1, 2016 hearing, the testimony of Ms. Ortega that she was present at the September hearing and understood the settlement was conditioned on CMS approval, and argument of counsel. The court concluded the settlement was conditioned on CMS approval of an MSA and accordingly denied Ms. Ortega’s Motion to Enforce Settlement and for penalties and attorney fees. Ms. Ortega filed a “Motion and Order for New Trial for Re-argument Only” and, after a hearing was held on August 21, 2017, this was also denied.

Ms. Ortega now appeals and asserts two assignments of error: (1) that the WCJ erred in finding the settlement of $120,000.00 did not need to be paid within thirty days of the judicial approval of the settlement agreement and therefore denying sanctions, and (2) that the WCJ erred in finding CMS approval was a suspensive condition that must be fulfilled before paying Ms. Ortega the $120,000.00 settlement.

 

Is need for CMS’s approval of the MSA a suspensive condition?

Ms. Ortega’s first assignment of error depends on the outcome of the second assignment of error, namely, whether the CMS approval of the MSA funding was a condition that suspended the payment of $120,000.00 to Ms. Ortega. The WCJ held that CMS approval was a suspensive condition. This court agrees and finds no manifest or legal error with this finding.

Louisiana Revised Statutes 23:1201(G) provides for penalties and attorney fees in workers’ compensation cases as follows: If any award payable under the terms of a final, non-appealable judgment is not paid within thirty days after it becomes due, there shall be added to such award an amount equal to twenty-four percent thereof or one hundred dollars per day together with reasonable attorney fees, for each calendar day after thirty days it remains unpaid, whichever is greater, which shall be paid at the same time as, and in addition to, such award, unless such nonpayment results from conditions over which the employer had no control. No amount paid as a penalty under this Subsection shall be included in any formula utilized to establish premium rates for workers’ compensation insurance. The total one hundred dollar per calendar day penalty provided for in this Subsection shall not exceed three thousand dollars in the aggregate.

A final, non-appealable judgment includes a workers’ compensation settlement agreement, and triggers La.R.S. 23:1201(G) upon court approval and entry into judgment. However, obligations may be suspended by a suspensive condition which prevents enforcement of the obligation until an uncertain event occurs. Conditions may be either expressed in a stipulation or implied by the law, the nature of the contract, or the intent of the parties. When the suspensive condition depends solely on the whim of the obligor, the obligation is null.

In Harrelson v. Arcadia, 10-1647 (La.App. 1 Cir. 6/10/11), 68 So.3d 663, writ denied, 11-1531 (La. 10/7/11), 71 So.3d 316, the first circuit found that a settlement agreement requiring CMS approval of funding for an MSA was a suspensive condition that suspended the obligation to fund the MSA account until CMS approval was received. The WCJ in this case correctly recognized that this case is factually like Harrelson. In Harrelson, the employer agreed to pay the claimant $125,000.00, with $42,010.00 of that amount to be placed in a MSA account to cover future medical expenses and $82,990.00 to be paid in one lump sum. The agreement further contained a clause stating that if CMS requires additional money be placed into the MSA, Bestaff/insurer will, at its option, pay all such additional amounts and comply with all Medicare requirements regarding such, or will withdraw the proposal for a MSA, and the claim for future medical care will remain open.

The agreement was judicially approved on December 10, 2009. The employer immediately paid the claimant $82,990.00 and withheld the remaining amount for the MSA funding while awaiting CMS approval. CMS ultimately approved the amount on January 27, 2010, and the employer issued a check for the balance of the funds on February 2, 2010, within thirty days of CMS’s approval, but over thirty days from the date of judicial approval of the agreement. The claimant then filed a motion to enforce settlement judgment seeking penalties and attorney fees pursuant to La.R.S. 23:1201(G) for the employer’s failure to pay the entirety of the settlement agreement within thirty days of the judgment. On appeal, the first circuit affirmed the WCJ, agreeing that the approval by CMS was an uncertain event that once it occurred made the WCJ’s order approving the entire settlement agreement final and enforceable.

As in Harrelson, the agreement between the parties in this case was that CMS needed to approve the funding of the MSA. The difference between this case and Harrelson, is that in Harrelson, $82,990.00 was to be paid in one lump sum regardless of the outcome of the CMS approval. In Harrelson, if CMS did not approve of the MSA funding, the employer had two options—to pay the additional amount requested by CMS or withdraw the proposal for a MSA. However, in the case before this Court, the calculation of the amount to be paid to Ms. Ortega in benefits is entirely dependent on the amount required to fund the MSA. The judicially approved agreement as evidenced by the court transcript was that if CMS does not approve the requested amount, but alters it in any way, we will fund the MSA as directed by CMS and then adjust the amount to be paid in benefits accordingly, so that the total of the settlement still amounts to $120,000.

Additionally, Exhibit P-2, submitted by Ms. Ortega and which is the affidavit of her counsel, states it was agreed that post-settlement documents would be prepared by defense counsel with the understanding that whatever amount for medical expenses was approved by CMS would be designated in the settlement documents as a full and final compromise of all claims for medical expenses and the remainder of the $120,000.00 settlement fund would be attributed to a full and final settlement of all claims for indemnity benefits, penalties and attorney fees.

Finally, the settlement documents signed by Ms. Ortega specify that Appellees would write two checks, one to Ms. Ortega, and one to the Mary Ortega MSA Account. Appellees could not possibly write these two checks without knowing the amount CMS approved to fund the MSA account. Therefore, the court agrees with the WCJ that the need for CMS’s approval of the MSA funding was a suspensive condition.

 

Does suspensive condition depend on the whim of the employer/carrier?

The next question is whether the suspensive condition depends on the whim of the employer/carrier, making the obligation null, or whether the employer had no control over CMS approving the MSA funding.

Ms. Ortega argues that the suspensive condition depends on the whim of the employer to file the request with CMS. This issue was also raised in Harrelson, however, in that case, the court received evidence that the request was in fact made to CMS, and therefore Appellees could not do anything more without the CMS approval. Ms. Ortega, on the other hand, asserts Appellees have not sought CMS approval and that there was no requirement in the settlement that Appellees do so within a certain timeframe. Therefore, under the WCJ ruling, Appellees can continue not funding the settlement because they were not required to obtain CMS approval by any specific date.

Ms. Ortega correctly stated that there is no evidence in the record that Appellees have sought CMS approval. The only contrary argument is just that, merely argument and not proof of fact. However, regardless of when Appellees apply for CMS approval, that approval will ultimately be beyond Appellees’ control. Therefore, the WCJ did not err in concluding that Appellees were not required to pay Ms. Ortega the settlement funds prior to CMS approval of the MSA funding.

 

Conclusion

Because the court concludes nonpayment was the result of conditions over which the employer/carrier had no control, the WCJ did not err in denying statutory penalties and attorney fees, in this case, for Appellees’ failure to pay the funds within thirty days of the final and non-appealable judgment.

This case brings to light the never-ending question of whether parties should submit their MSAs to CMS, or dispense with such approval and move forward without submitting their MSAs to CMS. It also questions whether settling a Medicare file contingent or dependent upon CMS approval of the MSA is still a worthwhile practice. Time and time again CMS has indicated such submission is not mandatory, but completely voluntary. But at the same time, CMS is quick to remind litigants that without such approval, CMS is not bound by any agreement, stipulation, or settlement of the parties. So, the answer still very much depends on the litigants’s appetite for risk. For the employer/carrier, what are the chances CMS may seek reimbursement of conditional payments made by Medicare associated with the claim a year, or two, or five down the road? For the claimant/counsel, what are the chances CMS may deny future care related to the claim; and if Medicare pays for same, what are the chances CMS may seek reimbursement of same?

Undeniably, more and more parties are choosing to forego CMS review and approval of MSAs. Coupled with professional administration of such MSA accounts, more and more litigants are finding ways to appropriately take Medicare’s future interests into account and become responsible stewards of the Medicare Trust Funds. But for those of us who still believe in total and complete closure, who never want any MSA issues to come back and create havoc, who want some measure of guarantee that CMS recognizes the parties have taken Medicare’s future interests into consideration, we continue to submit MSAs to CMS for their review and approval.

If the parties are going to make approval of the MSA by CMS a centerpiece of their settlement, as based on this case and the many others similarly decided by courts throughout the country over the years, it is important to be specific. So that you are not caught in the same situation the parties in this case were challenged by, here are a few items to think through and make sure are part of your mediation speaking points, or settlement agreement:

  • Who will be submitting the MSA to CMS?
  • Within how many days of settlement will the MSA be submitted to CMS?
  • If CMS requests further information, additional evidence, or workup, who will be responsible for obtaining same?
  • Within how many days must such information be provided? How many days to re-submit to CMS?
  • What happens if CMS doesn’t respond?
  • What happens if party responsible for providing updated or new evidence provides same late, or doesn’t provide it at all?
  • What consequences if submission deadlines are not met or abided by?
  • If CMS disagrees with MSA proposal and requests more than proposed, what happens? Who is responsible for extra funds?
  • What if parties change their minds after settlement, or even after submission to CMS, about lump sum vs. structured funding of the MSA?
  • Who is responsible for communicating same to CMS? Do the parties agree to seek CMS approval of this change?
  • If CMS changes the seed amount or the annual amount on structured funded MSA, how will such changes be handled? Will new annuity be purchased for extra amount?
  • What if claimant changes his/her mind about self-administration or professional administration?
  • Is it allowed? Who is responsible for communicating same to CMS? Do the parties agree to seek CMS approval of this change?

 

About Rafael Gonzalez

Rafael Gonzalez, Esq. is President of Flagship Services Group. He has over 30 years of experience in the auto, liability, no-fault, and work comp industries. He is one of the country’s top experts on Medicare and Medicaid compliance, serving insurers, self-insureds, and third party administrators. He speaks and writes on mandatory insurer reporting, conditional payment resolution, set aside allocations, and professional administration, as well as the interplay and effect of these processes and systems and the Affordable Care Act throughout the country. Rafael blogs on these topics at Medicare Compliance for P&C Insurers at www.flagshipservicesgroup.com/blog. He is very active on LinkedIn, Twitter, Instagram, and Facebook. He can be reached at rgonzalez@flagshipsgi.com or 813.967.7598.

 

 

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6th Circuit Denies Beneficiary MSP Double Damages for Not Alleging Personal Financial Loss and Therefore Not Establishing Standing

On April 16, 2018, the United States Sixth Circuit Court of Appeals published its opinion on Gucwa and Marusza v. Lawley, Ager, Baker, Rubin and Accident Fund Insurance Company, finding that because Gucwa and Marusza did not allege personal financial loss in the original complaint or the two amended complaints, they have not established standing to bring an MSP private cause of action for double damages.

 

Mark Marusza and Nancy Gucwa’s complaint alleged four causes of action in this matter: (1) Accident Fund and the defendant physicians defrauded Marusza, Gucwa, and others of benefits, in violation of the Racketeer Influenced and Corrupt Organizations Act; (2) Marusza is entitled to double damages under the Medicare Secondary Payer Act; (3) the defendant doctors tortiously interfered with Marusza’s contractual relationship and/or business expectancy by inducing Accident Fund to deny his benefits; and (4) Accident Fund falsely imprisoned Marusza by requiring him to attend an examination with a neuropsychologist. The analysis below focuses only on the MSP private cause of action for double damages.

 

Facts of the Case

 

A sport-utility vehicle struck Mark Marusza on October 18, 2011, while Marusza was in the course and scope of his employment. Marusza sustained injuries to his brain, shoulders, cervical spine, and ribs. Following his release from the hospital, Nancy Gucwa provided attendant care services for his brain and spinal injuries.

 

Marusza’s workers’ compensation carrier—Accident Fund Insurance Company— initially paid Marusza’s claims for Gucwa’s care but terminated payment in July 2012. Accident Fund retained the four defendant physicians—Dr. Jeffrey Lawley, Dr. Harvey Ager, Dr. W. John Baker, and Dr. Barry Rubin—to examine Marusza’s disability. Following the doctors’ reports, Accident Fund refused to pay for certain treatments, including drugs to control injury-induced aggression, psychiatric hospitalization, pain medication, attendant care, physical therapy, doctors’ visits, nurse case management, and surgeries for his neck, back, and shoulders.

 

As a result of Accident Fund’s refusal to pay for such care, Medicare paid $15,665.00 for such treatment. It is important to note that the opinion does not indicate or provide a breakdown of such payments. In other words, we do not know whether the payments made by Medicare were for drugs to control the injury-induced aggression, for the psychiatric hospitalization, for pain medication, for attendant care, for physical therapy, for doctors’ visits, for nurse case management, or for surgeries for his neck, back, and shoulders.

 

After Accident Fund’s denial of benefits, Marusza filed a workers compensation claim seeking payment of indemnity benefits and medical care associated with the injuries related to the accident with the Michigan Workers’ Compensation Agency. In May 2016, Workers’ Compensation Board Magistrate Beatrice B. Logan issued her opinion that Marusza required treatment for a mild traumatic brain injury, vision problems, and injuries to his neck, shoulders, and lower back caused by the 2011 accident. Because Marusza lost all wage earning capacity in the accident, Magistrate Logan ordered Accident Fund to pay Marusza workers’ compensation benefits owed from October 19, 2011, onward at the rate of $592.88 per week and for reasonable and necessary medical treatment of Marusza’s employment-related conditions. Based on this decision, on August 12, 2016, Accident Fund paid Marusza $74,382.00.

 

Prior to the Board’s decision and Accident Fund’s payment to Marusza, on March 5, 2015, Plaintiffs filed a complaint in the U.S. District Court for the Eastern District of Michigan naming Accident Fund and the four doctors as defendants. Plaintiffs filed their First Amended Complaint the next day. Each defendant moved to dismiss for failure to state a claim upon which relief can be granted in spring 2015.

 

Following the Board’s decision, Plaintiffs filed a Second Amended Complaint. In January 2017, the district court granted the defendants’ motions to dismiss each claim, denied Dr. Rubin’s and Plaintiffs’ motions for sanctions against each other, and denied Plaintiffs’ motion for leave to amend their Second Amended Complaint. Marusza and Gucwa, the plaintiffs, now appeal.

 

The Medicare Secondary Payer Act

 

Congress enacted the Medicare Secondary Payer Act in 1980 to reduce federal healthcare expenses. The Act makes Medicare a secondary payer for a beneficiary’s medical services when payment is available from a different primary payer, such as a workers’ compensation plan. 42 U.S.C. § 1395y(b)(2)(ii). If that primary payer neglects its obligation to pay for a particular medical service, Medicare can cover the cost conditionally and seek reimbursement from the primary payer. 42 U.S.C. § 1395y(b)(2)(B)).

 

The Act also creates a private right of action with double recovery against primary payers who fail to provide the appropriate payment or reimbursement. 42 U.S.C. § 1395y(b)(3)(A). Marusza alleges that Accident Fund defrauded Medicare by forcing them to pay $15,665.00 in medical bills for which Accident Fund was responsible. Marusza seeks double damages under the Act.

 

As the party invoking federal subject matter jurisdiction, Plaintiffs bear the burden of establishing “the `irreducible constitutional minimum’ of standing”: that the plaintiff “(1) suffered an injury in fact, (2) that is fairly traceable to the challenged conduct of the defendant, and (3) that is likely to be redressed by a favorable judicial decision.”  The district court dismissed Marusza’s claim under the Act because he had not alleged financial harm. The court here affirms that decision. Because the Medicare Secondary Payer Act is not a qui tam statute, the financial injury suffered by the government does not confer standing upon other parties. In other words, this court holds private plaintiffs seeking MSP private cause of action double damages must suffer their own individual harm.

 

Marusza argues that this circuit held in Stalley v. Methodist Healthcare, 517 F.3rd 911,919 (USCA 6th Cir. 2008) that a plaintiff has standing under the Act as long as they are a Medicare beneficiary denied coverage by a primary payer. The court concludes this misrepresents Stalley. The court instead indicates that Stalley stands for the proposition that a particular plaintiff seeking relief under the Act as a “self-appointed bounty hunter,” lacks standing under the statute if “he was not a Medicare beneficiary, Medicare eligible, or denied coverage by a primary payer.”

 

Establishing Standing

 

This court rules that a plaintiff does not satisfy the elements of standing simply by showing that the insurer failed to make payments “on his behalf”; the plaintiff must show that he “himself suffered an injury because a primary plan has failed” to pay. In other words, this court finds that Marusza must allege that he was injured by Accident Fund’s failure to pay. Because Marusza’s complaint alleged merely that Medicare suffered a financial injury when Accident Fund failed to pay, the complaint failed to establish that Marusza himself had standing.

 

After the district court’s decision, Marusza alleged for the first time in his February 6 motion for rehearing and reconsideration that he had suffered financial loss. The court concludes the district court correctly denied the motion because “a motion for reconsideration may not be used to raise issues that could have been raised in the previous motion.” Marusza had multiple prior opportunities to address the standing issue. Furthermore, the conclusory allegations in the affidavit stated simply that Marusza had to “pay co-pays because Medicare does not pay the entire bill,” but failed to provide any receipts, billing statements, or other information about the amount, recipient, or date of the co-pays.

 

Marusza argued that the district court should have granted him leave to amend his affidavit a third time to address the lack of standing. However, Marusza made no request for leave to address the lack of personal financial harm until the motion for reconsideration. On appeal, this court refuses to consider Plaintiffs’ affidavits from the motion for reconsideration because “arguments raised for the first time in a motion for reconsideration are untimely and forfeited on appeal.”

 

Conclusion

 

Because Marusza did not allege personal financial loss in the original complaint or the two amended complaints, he has not established standing. Thus, the court affirms the district court. “The case law of this Circuit and the state of Michigan forecloses Plaintiffs’ RICO, Medicare Secondary Payer Act, tortious interference, and false imprisonment claims. For the foregoing reasons, the district court’s order is affirmed.”

 

This case continues a trend I have been writing and speaking about for some time, that Medicare beneficiaries are fast becoming and will continue to seek to become plaintiffs in MSP private cause of action for double damages. It is surprising to note that the decision does not mention the marquee cases in the 6th Circuit that gave way to such claims, including the July 16, 2014, United States Court of Appeals for the Sixth Circuit opinion on Michigan Spine and Brain Surgeons, LLC v. State Farm Mutual Automobile Insurance Company (allowing Michigan Spine to pursue its claim under the Medicare Secondary Payer Act against State Farm without showing of any financial loss), the September 2, 2014, United States District Court for the Western District of Kentucky opinion on Estate of Clinton McDonald v. Indemnity Insurance Company of North America (concluding that based on USCA 6th Circuit decision on Michigan Spine Clinic v. State Farm, as the Estate’s filing of the law suit prompted payment in the amount of $184,514. 24, the Estate was entitled to double damages per the MSP Private Cause of Action provision without showing personal financial loss), or the February 17, 2016, State of Michigan Circuit Court for the County of Oakland opinion on Hull v. Home Depot (finding that although Home Depot had already paid $42,233.16 to Medicare and Blue Cross Blue Shield Medicare Advantage Plan, because Mr. Hull’s filing of the MSP private cause of action prompted Home Depot’s payment of same, Mr. Hull was entitled to double damages without showing personal financial loss).

 

I do not anticipate this case will stop Medicare beneficiaries from becoming plaintiffs in MSP private cause of action for double damages. I do however anticipate such plaintiffs spending a considerable amount of time elaborating and enumerating the various ways in which they may have sustained personal financial loss as a result of the primary payer’s failure to reimburse Medicare for any accident related medical expenses that should have been the primary payer’s responsibility. Unfortunately, this may further complicate matters for primary payers, as it may allow such plaintiffs to file state causes of action permitted under specific state laws to prevent such financial losses to plaintiffs. Stay tuned as I continue to keep you updated on such trends and case law.

 

About Rafael Gonzalez

Rafael Gonzalez, Esq. is President of Flagship Services Group. He has over 30 years of experience in the auto, liability, no-fault, and work comp industries. He is one of the country’s top experts on Medicare and Medicaid compliance, serving insurers, self-insureds, and third party administrators. He speaks and writes on mandatory insurer reporting, conditional payment resolution, set aside allocations, and professional administration, as well as the interplay and effect of these processes and systems and the Affordable Care Act throughout the country. Rafael blogs on these topics at Medicare Compliance for P&C Insurers at www.flagshipservicesgroup.com/blog. He is very active on LinkedInTwitter, Instagram, and Facebook. He can be reached at rgonzalez@flagshipsgi.com or 813.967.7598.

 

Rafael Gonzalez, Esq

 

About Medicare Conditional Payments

42 CFR Section 411.21 indicates that Medicare conditional payments are payments made by Medicare for medical treatment where a primary payer (insurer or self-insurer) has or may have an obligation to make such payment. Primary payers must reimburse Medicare for conditional payments it has made. 42 USC Section 1395y indicates that primary payers include group health providers, workers’ compensationliability and no-fault insurers and self-insured entities, as well as physicians, attorneys, hospitals, or clinics that receive payment from a primary payer must make reimbursement.

42 USC Section 1395y also indicates responsibility as a primary payer arises even if liability for the medical expense is contested. Such a responsibility can be demonstrated by entry of a judgment or by payment conditioned on a release or waiver of payment, even if liability is denied. 42 CFR Section 411.24 indicates Medicare has a direct right of action against all primary payers responsible for making payment. And, Medicare has a direct right of action against any person or entity that received a primary payment, including the Medicare beneficiary, medical provider, physician, attorney, state agency or private insurer.

 

About Medicare Advantage and Prescription Drug Plans Reimbursement

42 CFR Section 422.108(f) provides MAPs with the same rights of recovery that the Secretary of HHS has under the MSP regulations in subparts B through D of part 411 of 42 CFR. Additionally, the same MSP regulations at 42 CFR Section 422.108 are extended to PDPs at 42 CFR Section 423.462. Therefore, PDPs have the same MSP recovery rights as MAPs, which have the same recovery rights as HHS. This includes, as recent federal appellate and district court decisions have indicated, the ability to pursue double damages through MSP private cause of action pursuant to 42 USC Section 1395y(b)(3) should the primary payer deny the MAP or PDP reimbursement of any due conditional payments.

 

About Medicaid Third Party Liability Liens

42 USC Section 1396a mandates that all reasonable measures to ascertain legal liability for Medicaid payments and reimbursement of same be taken. The state or agency administering a Medicaid plan must take all reasonable measures to ascertain the legal liability of third parties to pay for care and services paid by Medicaid. Federal law also provides that in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual, the state or local agency must seek reimbursement for such assistance to the extent of such legal liability. 42 U.S.C. Section 1396a(a)(25).

 

About Flagship Services Group

Flagship Services Group is the premier Medicare and Medicaid compliance services provider to the property & casualty insurance industry. Our focus and expertise has been the Medicare and Medicaid compliance needs of P&C self-insureds, insurance companies, and third party administrators. We specialize in P&C mandatory reporting, conditional payment resolution, and set aside allocations. Whether auto, liability, no-fault, or work comp claims, we have assembled the expertise, experience and resources to deliver unparalleled MSP compliance and cost savings results to the P&C industry. To find out more about Flagship, our folks, and our customized solutions, please visit us at www.flagshipservicesgroup.com. To speak with us about any of our P&C MSP compliance products and services, you may also contact us at 888.444.4125 or info@flagshipsgi.com.