Summary
The Eleventh Circuit held that a Medicare Advantage Organization may bring a private cause of action under the Medicare Secondary Payer Act against a primary payer that fails to reimburse the organization’s secondary payment. The court affirmed summary judgment awarding Humana double damages and declaratory relief against Western Heritage Insurance Company.
Topics
Practice areas
Questions Presented
- Whether a Medicare Advantage Organization may bring the Medicare Secondary Payer Act's private cause of action against a primary payer that fails to reimburse the organization's secondary payment.
- Whether Western Heritage was a primary plan that failed to provide appropriate reimbursement under the Medicare Secondary Payer Act.
- Whether Humana was entitled to summary judgment and mandatory double damages of $38,310.82.
Holdings
- A Medicare Advantage Organization may use 42 U.S.C. § 1395y(b)(3)(A) to sue a primary plan that fails to make primary payment or reimburse the organization's secondary payment.
- Western Heritage failed to provide appropriate reimbursement because it had actual or constructive knowledge of Humana's claim and did not directly reimburse Humana within the applicable period.
- Humana was entitled to recover the full $19,155.41 secondary payment, and the MSP private cause of action required double damages of $38,310.82.
Key quotations
“Therefore, an MAO may avail itself of the MSP private cause of action when a primary plan fails to make primary payment or to reimburse the MAO’s secondary payment.” (1238)
“Therefore, the district court correctly ordered Western to reimburse Humana $38,310.82, double the amount to which Humana was otherwise entitled.” (1240)
Factual background
Mary Reale, a Humana Medicare Advantage enrollee, was injured at Hamptons West Condominiums, and Humana paid $19,155.41 for her medical treatment. Reale and her husband later settled their Florida tort action against Hamptons West and its liability insurer, Western Heritage, for $115,000, while representing that no Medicare lien existed. Humana issued an Organization Determination for $19,155.41, and Western attempted to include Humana as a payee or place that amount in trust but ultimately did not reimburse Humana directly.
Procedural history
Humana paid $19,155.41 in medical expenses for its Medicare Advantage enrollee after an injury caused by a condominium property. The enrollee settled a Florida tort action with the condominium association and Western Heritage, the association's liability insurer, but Western did not reimburse Humana. After related litigation involving the enrollee and dismissal of Humana's state-law claims, the district court granted Humana summary judgment and awarded double damages of $38,310.82. The Eleventh Circuit affirmed.