Category Archives: Medicare Jurisdiction

Blog, Medicare Conditional Payments, Medicare Jurisdiction, Trial Practice

The Medicare Secondary Payer (MSP) Private Cause of Action (PCOA) provides for double damages when a primary plan fails to pay for Medicare’s conditional payment.  See 42 USC §1395y(b)(3)(A).  How to trigger the primary plan’s responsibility under this law has been at the forefront of recent MSP decisions that have come down as of recent. The MSP PCOA is a …
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CMS Updates MMSEA Section 111 User Guide

09 Apr 2015 Roy Franco No Comments

Blog, Medicare Jurisdiction, Medicare Reporting Section 111

CMS released yesterday version 4.6 of the MMSEA Section 111 User Guide, dated April 6, 2015. Responsible Reporting Entities (RREs) when encountering instances of the disposition code “DP” for possible duplicate beneficiary situations, are instructed on what actions to take to remain in compliance. The new disposition code was added because of the SMART legislation which required CMS to curtail …
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Blog, Medicare Jurisdiction

Case:     Humana Medical Plan, Inc. v. Western Heritage Insurance Company, 2015 U.S. Dist. LEXIS 31875 Issue:    Is a Medicare Advantage Plan entitled to double damages when it is not repaid through a settlement? Held:     As a matter of law, Humana is entitled to maintain a private cause of action for double damages pursuant to 42 U.S.C. § 1395y(b)(3)(A). …
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Blog, Medicare Jurisdiction, Medicare Secondary Payer News, MSPRC Appeals

Effective April 28, 2015, Applicable Plans (Workers’ Compensation Law or Plans, Liability Insurance, No-Fault Insurance, and those who self-insure for casualty losses) will be able to appeal erroneous MSP Final Demand Letters directed by the Centers for Medicare & Medicaid Services (CMS) against these entities. This is a significant victory for such Plans and one that should be savored. A …
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CMS Administrator Marilyn Tavenner is Stepping Down

21 Jan 2015 Jesse Hamby No Comments

Blog, Medicare Jurisdiction

Marilyn Tavenner, a key Obama administration health official overseeing the country’s largest health insurance programs, announced Friday that she’s resigning from her position as administrator of the Centers for Medicare and Medicaid Services next month. Click here and here to read more about this important transition.

Magistrate’s Recommendation Rejected in Humana Case

29 Sep 2014 Roy Franco No Comments

Blog, Medicare Conditional Payments, Medicare Jurisdiction, Medicare Secondary Payer News, Pharma Part D, Reimbursements, Trial Practice

This past March we wrote about the Magistrate’s recommendation to the Judge handling the Humana Insurance Co. v. Farmers Texas County Mutual Insurance Co. Cause No. 13-CV-611-LY to dismiss the claim. Our analysis of that recommendation can be found here. In brief, we compared the decision process to a boxing match that would inevitably end up in the appellate courts. …
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House and Senate Send Bipartisan Letter to CMS

04 Aug 2014 Katie Fox No Comments

Blog, Medicare Jurisdiction, Medicare Secondary Payer News

On July 30, 2014, the House took actions parallel to the Senate by sending a bipartisan letter about the implementation of SMART to CMS.  We again applaud Congress’ actions for the letters and MARC for continuing its advocacy to increase MSP compliance.  We continue to urge all of our clients and friends to consider joining MARC to continue this important advocacy.  Legislation alone does …
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Blog, Medicare Jurisdiction

The Medicare Manual is cited, the definition of Primary Plan is questioned, and the quasi nature of a court “hearing” is addressed, among other interesting Medicare Secondary Payer issues, in Taransky, Individually and on behalf of all persons similarly situated v. Secretary of the US Department of Health and Human Services, US Department of Health and Human Services, and United …
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Blog, Medicare Jurisdiction, Medicare Secondary Payer News

Circuit Courts are in conflict over the application of the private cause of action within the Medicare Secondary Payer Act (MSP).  42 U.S.C. § 1395y(b)(3)(A) is the section of the MSP law allowing lawsuits against  primary plans if such plan is responsible to pay for medical items and services related to the claim, but somehow failed in that responsibility, causing …
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