Category Archives: Reimbursements

Blog, Medicare Conditional Payments, Medicare Secondary Payer News, Reimbursements

The California Insurance Guaranty Association (CIGA) is California’s largest workers’ compensation provider as the insurer of last resort for employers who would otherwise not be able to afford the mandatory coverage.  Because it operates for all intents and purposes as an adverse risk pool, it must exercise care in payments it makes for worker’s compensation claims that result.  Consequently, when …
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Blog, Legal/Legislative News, Medicare Jurisdiction, Medicare Secondary Payer News, Pharma Part D, Reimbursements

The Medicare Advocacy Recovery Coalition (MARC) worked diligently over the past eighteen months to develop and introduce the Secondary Payer Advancement, Rationalization and Clarification Act of 2016 (SPARC). Representatives Tim Murphy (18th District Pennsylvania, Republican) and Ron Kind (3rd District Wisconsin, Democrat) sponsored this bipartisan legislation that was immediately referred to the two committees of jurisdiction over Medicare – House …
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Blog, Medicare Conditional Payments, Reimbursements

In a decision out of the Court of Appeal of California, Karpinski v. Smitty’s Bar, Inc., 2016 Cal. App. LEXIS 277 (April 12, 2016), the Court affirmed the trial court’s decision to enforce a settlement between the Parties, despite the Defendant, Smitty’s Bar (“Smitty’s”) objections and attempts to delay settlement to ensure reimbursement of liens, particularly Medicare conditional payments. The …
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Blog, Medicare Conditional Payments, Reimbursements

We recently blogged on CMS’ announcement regarding maintaining the $1000 settlement threshold for liability insurance (including self-insurance) wherein CMS would not require reimbursement of conditional payments and would not require Section 111 reporting. CMS is required to annually produce a liability threshold amount pursuant to the SMART Act. Our prior blog can be accessed here. Since then, CMS has released …
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Blog, Legal/Legislative News, Medicare Conditional Payments, MSPRC, Reimbursements

In a decision out of the Supreme Court of Iowa, an attorney, Paul Silich’s (Silich) law license has been suspended for thirty days for failure to timely handle and reimburse Medicare conditional payments and for violating several ethical attorney professional rules. The background of the case involved Silich’s legal representation of a Medicare beneficiary, Nancy Sanderson (Sanderson), who fell out …
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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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Blog, Medicare Conditional Payments, Medicare Reporting Section 111, Reimbursements

In Nawas v. State Farm Mut. Auto. Ins. Co., 2014 U.S. LEXIS 128365, a District Court within the 6th Circuit decided whether there existed a “condition precedent” requiring plaintiff to establish “demonstrated responsibility” of the defendant before plaintiff could proceed with a Medicare Secondary Payer private cause of action.  Under 42 U.S.C Section 1395y(b)(3)(A), a primary plan is subject to …
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Blog, Medicare Jurisdiction, Reimbursements

This past February, CMS published a MSP exemption as required by the SMART legislation.  On November 15th of each year, SMART requires the Secretary to publish calculations for this important exemption that applies liability settlements, judgments, awards or other payments involving physical trauma.  Once published the rate would take effect for the following calendar year.  Presently, the threshold amount is set …
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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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