Source: http://msp906.blogspot.com/
Timestamp: 2019-04-24 01:49:48+00:00

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The Florida Medicare MAOists are spreading nationwide. See our previous postings about these entities, which had previously limited their activities to Florida - 1 - 2 - 3.
At least 14 different lawsuits have been filed in several Federal district courts by a company called MAO-MSO Recovery II, LLC and by related companies. The following listing is taken from the most recent decision of the court in the case filed in the Western District of Wisconsin. In no case has the company been permitted to proceed. In a couple of cases, the complaint has been dismissed outright. In others, a motion to dismiss is pending or has been granted, with leave granted to amend the complaint.
MAO-MSO Recovery II, LLC v. Boehringer Ingelheim Pharm., Inc., No. 17-cv-21996-UU (S.D. Fla.) (motion to dismiss granted with leave to replead).
None of the cases, it appears, relate to any actual claims or lawsuits in which Medicare expenses are involved. Rather, they are complaints which purport to state a class action claim against a single insurance company, alleging that the company has settled lawsuits brought by enrollees in unidentified Medicare Advantage plans, that the reimbursement rights of the MA plans have been disregarded in the settlements, that reimbursement money is owed, and that the plaintiff entity is the assignee of the rights of the MA plan.
First, defendants say that plaintiffs have not adequately alleged that they have standing to sue because the complaints do not include facts showing that they have a valid assignment from a particular MAO as to any particular claim against either defendant. Second, defendants say that plaintiffs have not adequately alleged the elements of their claims, including that defendants were the primary payer of a particular medical expense, that defendants failed to a pay a particular medical expense that they were required to pay, that a particular MAO paid a particular claim, or that a particular beneficiary was a member of a particular MAO.
The court, District Judge James D. Peterson, has dismissed the complaint but (like many of the other District Courts) has given MAO-MSO an opportunity to amend its complaint to see if it can come up with a better (and legally cognizable) statement of a claim.
Meridian Health Plan, a Medicaid HMO, had received billings for apparently related medical expenses in the amount of $298,869.10, of which it paid $110,283.19, about 37% of the total. First Recovery Group, on behalf of Meridian, asserted its lien in that amount.
All or almost all Medicaid payments in Michigan are now handled by Medicaid HMOs.
Most of the Medicaid HMOs have a contract with First Recovery Group to handle its reimbursement claims.
First Recovery Group is typically very resistant to any attempts to compromise the amount of its lien. Its position is that the payments by the HMO have already reduced the amount of the provider charges significantly, thus saving the tort defendant a large part of the medical expenses.
Under the Ahlborn rule, however, the Medicaid payer is required to limit its reimbursement claim to a proportion of the medical expenses which corresponds to the proportion by which the tort claimant has compromised her claim in the course of settling the case. If the total value of the plaintiff's damages was $1 million, and she settles for $350,000, under the Ahlborn rule the Medicaid payer must also take 35% of its reimbursement claim.
The Circuit Court ruled in favor of Meridian and ordered that the entirety of the $110,283 amount be repaid. The Court of Appeals reversed, holding that, under Ahlborn, the Medicaid payer is permitted only to recovery "that portion of a settlement that represents payment for medical care." Under the Federal anti-lien provision, 42 USC 1396p-a-1, no lien may be imposed for repayment of Medicaid benefits on property of the Medicaid recipient, and that includes the other portions of the settlement.
The Court of Appeals did recognize that the courts cannot simply accept the agreement of the parties as to the amount allocated to medical expenses. But, it noted, the Circuit Court made no findings as to allocation at all. It simply held that the entirety of the lien amount must be repaid.
The Court therefore remanded the case to the Circuit Court for a hearing to determine the fairness and reasonableness of the settlement, and to determine a proper and fair allocation of damages among the categories of losses. The court further held that Meridian must contribute to the "costs of recovery," attorneys' fees and costs, and reduce the amount of the lien accordingly.
Another FHCP / La Ley / MSPR case has been decided by the Federal District Court in Miami, and this time the court has dismissed the case on its finding that the plaintiff, MSPA Claims 1, LLC, does not have standing to pursue a Medicare Secondary Payer recovery action against an alleged primary payer. MSPA Claims 1, LLC v. Infinity Auto Insurance Company, Case No. 16-20320-Civ, decided August 30, 2016.
We have been following this series of lawsuits for some time now. See our September 2015 post.
The court reviewed the language of the assignment agreements. Florida Health Care Plus (FHCP) entered into a written agreement with La Ley Recovery Systems, Inc. assigning its MSP reimbursement rights (including alleged private cause of action and double recovery claims) to La Ley. Under that agreement, La Ley could further assign the rights to another entity, but only on FHCP's approval. There was no averment in the complaint that such approval had been granted, and thus no showing that the condition to a valid sub-assignment had been met.
MSPA Claims 1, LLC v. Kingsway Amigo Ins. Co., No. 16-CV-20212-JLK, ECF No. 35 (S.D. Fla. July 27, 2016).
The court made note of a filing that had been made in state courts in Leon County, involving the Florida Department of Financial Services, said to be acting as "receiver" for FHCP, La Ley, and MSPA Claims 1, LLC. No further information about this filing is available at this point.
The 11th Circuit Court of Appeals, the court which ten years ago issued its landmark decision in Glover v. Liggett Group, Inc., 459 F. 3d 1304 (11th Cir. 2006), has now handed down an important opinion that defines and limits the scope of that ruling, and does so in a way that is very instructive to those of us who have to deal with the misunderstandings on this subject engendered by the 6th Circuit. The case is MSP Recovery, LLC, et al. v. Allstate Insurance Company, et al., 835 F.3d 1351 (11th Cir. 2016).
This is another in a series of cases addressing the question of when a litigant may include a claim under the "private cause of action" provided under the Medicare Secondary Payer statute when a claim for payment of insurance benefits is made. As our clients are aware, the private cause of action includes a provision permitting a claim for double recovery under certain circumstances.
As a quick sketch: In Glover, the 11th Circuit had held that a plaintiff who had sued cigarette manufacturers under the private cause of action and double recovery provisions of the Medicare Secondary Payer statute - but who themselves had not sustained any injuries - did not state a claim under which relief could be granted, because the defendants had not been demonstrated (by a judgment, a settlement, or other means, using the statutory language) to be legally responsible for the medical expenses incurred by Medicare beneficiaries who smoked cigarettes.
The primary problem that the Bio-Medical court's language creates for Michigan no-fault insurers is that an auto policy is also a contract. Unlike group health insurers, which have a plenary obligation to pay all medical expenses incurred by the insured (subject to deductibles and copayments), the no-fault insurer has an obligation to pay only medical expenses "arising out of the ownership, operation, maintenance or use of a motor vehicle as a motor vehicle." MCL 500.3105.
The MSPR case involved seven different lawsuits brought by the plaintiff as assignee, against four different liability insurers. In each case, the District Court had dismissed the claim under Glover, for the reason that the obligation of the insurer had not yet been demonstrated. MSPR asserted that the existence of a contractual obligation can be sufficient to demonstrate the insurer's responsibility to pay and thus there is no requirement that the responsibility be established by judgment or settlement. The defendants argued that, even when their obligation to their insureds exist under contract, the obligation must still be established independently in a court proceeding leading to a judgment or settlement.
The MSP Act permits demonstration of a primary plan's responsibility to pay "by a judgment, a payment conditioned upon the recipient's compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary plan or the primary plan's insured, or by other means." 42 U.S.C. § 1395y(b)(2)(B)(ii).
The position argued by the defendants, it concluded, would render the "or by other means" language superfluous.
The regulations adopted by CMS, at 42 C.F.R. § 411.22(a), state that responsibility may be demonstrated by a judgment entered after a verdict or "other means, including but not limited to a settlement, award, or contractual obligation."
"We hold that a contractual obligation may serve as sufficient demonstration of responsibility for payment to satisfy the condition precedent to suit under the MSP Act. This does not relieve Plaintiffs of their burden to allege in their complaints, and then subsequently prove with evidence, that Defendants' valid insurance contracts actually render Defendants responsible for primary payment of the expenses Plaintiffs seek to recover."
This is a much more reasoned approach. Unlike Bio-Medical, which simply declared (in dictum) that the demonstrated responsibility standard is irrelevant when a claim is based on contract, the MSPR Court said that a contractual obligation may, in a proper case, be sufficient to demonstrate that the insurer has a responsibility to pay the medical expenses in question.
It is a point of interest that the Court in the new MSPR case made no mention of the 6th Circuit's decision in Bio-Medical.
The U.S. Circuit Court of Appeals for the 11th Circuit, on appeal from a Florida District Court, issued its opinion in the case of Humana v. Western Heritage Insurance on August 8. This is yet another decision accepting the Avandia approach and rejecting the Care Choices approach to the ongoing question of whether and to what extent a Medicare Advantage plan is in the same position as CMS under ordinary Medicare when it comes to reimbursement obligations. This decision and the facts leading up to it have some differences from earlier decisions.
Executive Summary: The court accepted the Avandia analysis and allowed a claim for reimbursement as against a primary payer, in this case a liability carrier after settlement, without requiring or even inquiring whether its plan documents provide for such reimbursement. The court went further and approved a double recovery on behalf of Humana.
The case arose out of a lawsuit brought by Mary Reale against Hamptons West, a condominium association, for unspecified injuries. Humana had paid $19,155.41 in medical expenses, and later Reale and her husband settled with Hampton West for $115,000. The parties took steps to account for the Humana claim, agreeing to a holdback by plaintiff's counsel pending resolution of the reimbursement claim.
Humana first sued in Federal court. Reale sought dismissal based on lack of Federal jurisdiction, and the court granted that relief. Humana then sought reconsideration but then elected to dismiss the lawsuit voluntarily before the court could rule, apparently because another lawsuit had been filed in the interim.
Thus, at this point, the Federal courts and the state courts had both determined that the claim should be handled under the other system. The attorney for Reale had the reimbursement funds in his account, under the agreement. But what happened to those funds after that point is not clear.
One step was taken here which has not been taken in other cases: Humana sued the liability carrier, Western Heritage Insurance, for the reimbursement amount and for double damages under the Medicare statute in Federal court, well before the state court action was resolved. Summary judgment in favor of Humana's position was granted in March 2015.
The Circuit Court of Appeals, affirming, ruled and reasoned as follows.
Humana did not assert that it had an implied cause of action under the Medicare Advantage statute, 42 USC 1395ww-22(1)(4), and did not assert that it could pursue a reimbursement claim that is authorized in favor of CMS under the MSP statute. Rather, it asserted that it, like any other private party with standing, had the right to pursue its claim as a "private cause of action" under a different part of the MSP statute, b-3-A.
The court agreed further that Humana was entitled to a double recovery, even though Western Heritage had taken steps to protect Humana's interest by requiring an agreement from Reale that the funds needed to make reimbursement be held in trust by Reale's attorney. The court held that the demand letter plus 60 days time limit provided under the statute, and the provision under the CMS regulation that permits a reimbursement claim "event though [the primary payer] has already reimbursed the beneficiary," precluded that position.
Subparagraph (B) empowers the Secretary of Health and Human Services to make payments conditioned on reimbursement of the Medicare Trust Funds, but it says nothing about Medicare Advantage Organizations. Medicare Advantage Organizations instead charge primary plans in accordance with section 1395w-22(a)(4). Because Humana is not the Secretary and its coffers are not the Trust Funds, it cannot seek payment or reimbursement "in accordance with paragraphs (1) and (2)(A)." For that reason, section 1395y(b)(3)(A) creates no private cause of action for a Medicare Advantage Organization. . .
Subparagraph (B) also gives the Secretary a cause of action to recover reimbursement against primary plans, and subrogates the United States to any right to payment under a primary plan. A Medicare Advantage Organization receives no authority from paragraphs (1) and (2)(A). . .
The fact of Judge Pryor's dissent, and the contrast of the emerging line of pro-Avandia cases with the opposing line of Parra-Care Choices decisions, may make it more likely that the U.S. Supreme Court will agree to accept this case for consideration and, perhaps, finally give us all a definitive ruling on these continuingly thorny issues.
The Centers for Medicare and Medicaid Services (CMS) is considering expanding its voluntary Medicare Set-Aside Arrangements (MSA) amount review process to include the review of proposed liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS plans to work closely with the stakeholder community to identify how best to implement this potential expansion. CMS will provide future announcements of the proposal and expects to schedule town hall meetings later this year. Please continue to monitor this website for additional updates.
CMS has been considering how to address Medicare Set-Asides in connection with liability claims for many years now, but its approach has always been haphazard.
Be alert. Every time CMS says anything about MSAs in liability cases, there is a rush of poorly-informed sources who announce that MSAs "are now being required" in liability cases. There is no reason to expect anything different this time.
The U.S. District Court for the Eastern District of Virginia issued a decision in the case of Humana Insurance Company v Paris Blank, LLP on May 10, 2016. The unidentified Medicare beneficiary, identified only as "Enrollee," incurred medical expenses of over $190,000 in a motor vehicle accident. She later recovered a total of $455,600 from several defendants.
The issue presented was whether Humana's Medicare Advantage plan could assert a claim for recovery of its payments. The court considered only the Medicare statutes and regulations; there is no discussion in the opinion about whether Humana's contract language included a right of reimbursement, and no discussion about whether the Medicare statute requires that such language be included. Instead, the court simply accepted Humana's contention that its payments were "conditional payments" under the MSP statute, and it elected to give Chevron deference to the regulation adopted by CMS at 42 CFR 422.108, declaring that MA plans have the same right of reimbursement that CMS has for ordinary Medicare.
The court did cite and consider several of the cases that have held otherwise, including Parra v. PacifiCare of Ariz., Inc., 715 F.3d 1146 (9th Cir. 2013) but did not mention Care Choices HMO v. Engstrom, 330 F.3d 786 (6th Cir. 2003), the prominent Sixth Circuit decision that requires that an MA plan adopt express reimbursement language before such a right may be enforced.

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