Opinion ID: 2599663
Heading Depth: 2
Heading Rank: 1

Heading: The Governing Statute and Regulations

Text: A court's primary task in interpreting a statute is to give effect to the legislative purpose underlying its enactment. See Griffin v. Devanney, 775 P.2d 555, 559 (Colo. 1989). To determine the legislative purpose, we first look to the language of the statute itself, giving words and phrases their commonly accepted and understood meaning. See id.; see also Askew v. Industrial Claim Appeals Office, 927 P.2d 1333, 1337 (Colo. 1996). The limiting charge statute states: (1) Any provider of services . . . shall be qualified to participate under this subchapter and shall be eligible for payments under this subchapter if it files with the Secretary an agreement (A) not to charge . . . any individual or any other person for items or services for which such individual is entitled to have payment made under this subchapter.. . . 42 U.S.C. § 1395cc(a). The statute applies to payments made by Medicare under subchapter 18 of the Social Security Act, which includes both primary and secondary payments. Under the primary payer statute, these costs are limited to the DRG amounts. Under the secondary payer statute, these costs are limited to costs that are reasonable and necessary or customary. See 42 U.S.C. § 1395(f). The limiting charge statute clearly constrains a provider's ability to seek additional payment from a beneficiary when a beneficiary is entitled to Medicare payments. However, the statute does not address the situation where a no-fault insurance company is identified as the primary insurer for the medical costs incurred after Medicare makes a conditional payment. Consequently, the statute is of little help in resolving the question at hand. [8] Nevertheless, the agency in charge of implementing the Medicare provisions, the (DHHS), has implemented regulations to address this particular situation. If a statute is silent or ambiguous with respect to a specific issue, we give great deference to an agency's interpretation of the statute, looking only to whether the agency's regulation is based on a permissible construction of the statute. See Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 843, 104 S.Ct. 2778, 81 L.Ed.2d 694 (1984); U.S. West, Inc. v. Federal Communications Comm'n, 182 F.3d 1224, 1231 (10th Cir.1999). Section 411.35 of the Code of Federal Regulations in particular addresses the situation where a provider seeks to obtain payment from a beneficiary who has received payment from a third party payer, stating: [T]he amounts the provider or supplier may collect or seek to collect, for the Medicare-covered services from the beneficiary or any entity other than the workers' compensation plan, the no-fault insurer, or the employer plan are limited to the following: (1) the amount paid or payable by the third party payer to the beneficiary. If this amount exceeds the amount payable by Medicare . . . the provider or supplier may retain the third party payments in full without violating the terms of the provider agreement. . . . (Emphasis added.) This regulation directly addresses the situation presented here: the medical providers who treated Smith are seeking to collect the amount paid by Farmers to Smith for Medicare-covered services. The regulation explicitly states that a provider is not limited to the amount of conditional payment made by Medicare once a third-party payer is obligated to make payment. [9] Section 411.35 applies when another health insurer is primary to Medicare services, and limits the amount a provider can collect or seek to collect to the amount paid or payable to the beneficiary by the primary insurer. In the case before us, Farmers is the primary insurer. The providers can collect the amount paid by Farmers to the beneficiary for the Medicare-covered services. The statute acknowledges that this amount may exceed the amount payable by Medicare, and states that a provider may collect the full amount without violating 42 U.S.C. § 1395cc(a)(1)(A). The underlying policy of the MSP statute supports this interpretation.