Category Archives: Medicare Advantage Part C

Blog, Medicare Advantage Part C, Medicare Reporting Section 111

At Franco Signor we are seeing a steady increase in post-settlement requests being sent from Medicare Advantage Plans (MAPs) to claimants looking for confirmation of coverage.  The reason this is happening is simple: CMS requires defendants to report settlements with Medicare beneficiaries.  Included in the long list of data in such Reports is information about the defendant and/or Third-Party Administrator …
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Blog, Medicare Advantage Part C, Reimbursements

In Cupp vs. Humana, the Federal District Court granted Humana, a Medicare Advantage Plan, dismissal of the complaint against it.   The Medicare beneficiary was involved in an automobile accident and injured. He presented a claim against the responsible driver, and its insurer (State Farm), agreed to settle for $25,000.  Shortly, after such resolution, Humana, the Medicare beneficiary’s health plan, asked …
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Medicare Advantage Plan Loses Another Round

11 Mar 2014 Roy Franco No Comments

Blog, Medicare Advantage Part C, Reimbursements

The Medicare Advantage Plan’s (MAP) struggle to establish reimbursement rights on par with traditional Medicare can be compared to a championship boxing match. It’s the middle of Round 4 and the MAP has been knocked down for the second time.   Parties responsible for MSP compliance want a knockout and final victory proclaimed. However, no one can believe the fight is …
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Humana’s Suit Against Farmers in Texas — UPDATE

23 Jan 2014 Roy Franco No Comments

Blog, Medicare Advantage Part C, Pharma Part D

We previously blogged about lawsuits brought by Humana against Farmers Insurance in four jurisdictions across the country.  We have been informed that Humana voluntarily dismissed three of the complaints (Tennessee, Missouri and Kansas), however the case brought in Texas is moving forward. Recently, Farmers moved to dismiss Human’s Texas litigation.  That motion is being rigorously opposed by Humana in the …
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ALERT- Medicare Advantage Appeals Update

24 Jul 2013 Roy Franco No Comments

Blog, Medicare Advantage Part C

Humana, Inc., a private health insurer which offers Medicare Advantage and Part D prescription coverage to Medicare beneficiaries, has filed lawsuits in four District Courts (Eastern Tennessee, Kansas, Western District of Missouri and the Eastern District of Texas) to expand its reimbursement rights under the Medicare Secondary Payer Act.  The target defendant is the Farmers Insurance Group, but it may as well …
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Blog, Medicare Advantage Part C

This case involves the Medicare Act, one of “the most completely impenetrable texts within human experience.”  See Cooper Univ. Hosp. v. Sebelius, 636 F.3d 44, 45 (3 Cir. 2010).  We could not agree more, as a conflict now exists between Circuits on the rights of a Medicare Advantage Plan (including Part D) under the Medicare Secondary Payer Act.  The Third …
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Blog, Medicare Advantage Part C, Medicare Secondary Payer News

Facts: A class of plaintiffs filed suit in state court against 40 Medicare Advantage (MA) Plans.  Defendants removed the action to federal court.  Plaintiffs allege that the MA reimbursement claims violate Section 5-335 of the NY General Obligations Law.  Plaintiffs’ action seeks restitution of all monies wrongfully collected by defendants and a permanent injunction “directing defendants to cease and desist …
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Medicare Advantage Part C, Medicare Secondary Payer News, Pharma Part D, Uncategorized

We previously wrote on the In Re Avandia decision granting new Medicare Secondary Payer powers to Medicare Advantage and Part D Plans.  As predicted, such Plans are bullish over their new authority.  Letters are being sent by Part C and Part D Medical carriers addressed to insurance carriers and self insureds who are settling or otherwise responsible to make payment …
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Blog, Medicare Advantage Part C, Medicare Conditional Payments, Medicare Jurisdiction, Pharma Part D

Potts vs. Rawlings Company LLC- 2012- U.S. Dist. Court for Southern Dist. NY Facts: This interesting case involves a putative class action against Medicare Advantage (MA) Plans, including Part D Drug Plans.   Plaintiffs sought protection from defendants’ reimbursement claims for conditional payments under New York State General Obligation Law §5-335.  Because this State Law prohibits Defendants, as benefit providers, from …
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Medicare Advantage Part C, Medicare Conditional Payments, Pharma Part D

Overview Humana, a Medicare Advantage Plan, used the Medicare Secondary Payer Private Cause of Action (42 U.S.C. Section 1395y(b)(3)(A) to bring suit against a self insured primary plan.  The lawsuit was brought in Federal Court to recover damages for the failure of the primary plan to reimburse or otherwise provide for primary payment of medical items and services related to …
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