Robert J. Finley No Comments

Key moments, thus far, to review and consider on the 2019 Medicare Secondary Payer voyage. Medicare Secondary Payer compliance can be complex with many changes to track from different and connected sources which affect administrative policies, procedures and processes.  Flagship’s educational solutions are thoughtfully designed to explain matters in simple terms which help your team be informed and equipped to seriously chart an easier and safer compliance course.

  1. The United States continues to target Plaintiff personal injury law firms as recipients of primary payments with allegations of failing to reimburse Medicare payments from settlement monies. Philadelphia Personal Injury Law Firm Agrees to Start Compliance Program and Reimburse the United States for Clients’ Medicare Debts Maryland Law Firm to Pay the United States $250,000 to Resolve Unreimbursed Medicare Payments on behalf of firm client United States v. Angino Law Firm, et al., 2019 U.S. Dist. LEXIS 30499 (M.D. Pa.)
  1. Closer scrutiny of CMS Conditional Payment Notices has found a prevalence of claims for past treatment unrelated to the occurrence, as well as occasional claims for treatment incurred subsequent to a liability settlement.
  1. Important case law developments on Medicare Advantage Organization assignees MSPA private cause of action litigation in First Circuit (MSP Recovery v. Plymouth Rock Assur. Corp., 2019 U.S. Dist. LEXIS 119499 (Mass.) and Eleventh Circuit (MSPA Claims 1, LLC v. Tenet Fla., Inc., 918 F.3d 1312)

In Plymouth Rock, Defendant auto insurer’s motion to dismiss Plaintiff’s MSPA putative class action is denied where Plaintiff holds a facially valid irrevocable assignment for which there is a valid cause of action under MSPA Private Cause of Action, whereas Defendant’s motion is granted striking Plaintiff’s class claim. The validity of Plaintiffs’ assignments is a fundamental element of its cases and, consequently, a frequently contested issue (compare with MSPA Claims 1, LLC v. State Farm Mut. Auto Ins. Co., 2019 U.S. Dist. LEXIS 34386 (S.D. Fla. 2019; MSP Recovery Claims, Series LLC v. QBE Holdings, Inc., 2019 U. S. Dist. LEXIS 57926 (M.D. Fla. 2019; MSPA Claims I, LLC v. Infinity Prop. & Cas. Grp., 374 F. Supp. 3d 1154 (N.D. Ala. 2019), but the Plymouth Rock court also discussed  key issues specific to an MSPA Private Cause of Action including a primary payer’s “demonstrated responsibility”, unnecessary “recovery demand letter”, and what event triggers the 3-year statute of limitations.

In Tenet, the 11th Circuit Court of Appeals affirmed the Southern District of Florida court’s decision granting Defendant’s motion to dismiss Plaintiffs’ MSPA Private Cause of Action where Defendant is a medical center because MSPA Private Cause of Action’s “remarkably simple…clear textual bar” is only available in the case of a primary plan which fails to provide primary payment or appropriate reimbursement.  The effect, if any, of Tenet on MSPA Claims 1, LLC v. Bayfront HMA Med. Ctr., LLC, 2018 U.S. Dist. LEXIS 44913 (S.D. Fla. 2018) is pending appeal.  The district court in Bayfront reached a different conclusion than Tenet finding a private cause of action could be brought against a medical provider that allegedly received a primary payment from an MAO and did not provide appropriate reimbursement.

  1. Awareness and activity in third party liability and repayment compliance administration coinciding with Medicare Advantage marketplace growth trends in enrollment, plans offerings, and expanding non-traditional Medicare benefits. Kaiser Family Foundation analysis of CMS Medicare Advantage Landscape, Enrollment and Benefit Files, 2019. A Dozen Facts About Medicare Advantage in 2019
  1. The PAID Act is currently still just a bill which, if it becomes law, would allow Applicable Plans to query whether a claimant is, or during the preceding 3-year period has been, eligibility for benefits under the Medicare program, Medicare Advantage plans and Medicare prescription drug plans.
  1. NPRM on Section 111 fines vs. Liability, No-Fault and WC insurance published action date September 2019 proposes to remove obsolete civil money penalty regulations and also replace obsolete regulations by soliciting public comment on proposed criteria and practices for which civil money penalties would and would not be imposed.
  1. NPRM on Liability Medicare Set-Asides published action date October 2019 providing beneficiaries and their representatives options to select for meeting future medical obligations and protecting the Medicare Trust Fund.
  1. Updated WCMSA Reference Guide 2.9 with “reasonable expectation” illustrations at Section 8.1 showing Medicare considerations irrespective of workload review thresholds.
  1. Medicaid Expansion and State reimbursement program changes. 50 State Primer on Medicaid Recovery Laws
  1. State of Michigan revised its No-Fault/PIP Auto Insurance law, Enrolled Senate Bill No 1, that includes at Section 3107d an option for certain Medicare beneficiaries to Elect No PIP Coverage after July 1, 2020

About Flagship: Flagship Services Group is the premier Medicare and Medicaid compliance services provider to the property & casualty insurance industry. Our focus and expertise have 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 team, 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.

 

About the Author:

Robert J. Finley, a partner at Hinshaw & Culbertson LLP, has litigation and trial practice experience focused in tort, employment and healthcare. He counsels firm clients under auto, property/casualty, no-fault, and workers compensation policies on Medicare repayment and Medicaid reimbursement compliance. Robert also advises Flagship Services Group on high value matters, in administrative hearings, and with educational solutions.

 

This publication is provided for informational purposes only.  It is not intended to constitute, and shall not be construed as, the rendering of legal, accounting, or business advice or opinion or professional services of any type.  Any opinions expressed in this publication are those of the author.  Nothing herein constitutes the views of Hinshaw & Culbertson LLP or its clients or the endorsement of any particular case, principle, or proposition.  The contents of this publication should not be viewed as a substitute for the guidance, advice, or recommendations of a retained professional.

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