Summary
The Eleventh Circuit affirmed dismissal of MSPA Claims 1, LLC’s Medicare Secondary Payer Act claim against medical providers. The court held that MSPA had standing as an assignee to pursue an alleged injury from delayed reimbursement, but the private cause of action under the MSP Act permits suits only against primary plans, not medical providers. The court also rejected arguments based on statutory cross-references and CMS regulations.
Topics
Practice areas
Questions Presented
- Whether MSPA Claims 1 had Article III standing as the assignee of FHCP's claim for delayed reimbursement.
- Whether the anti-assignment clause in the Hospital Services Agreement barred assignment of FHCP's statutory MSP Act claim.
- Whether the MSP Act's private cause of action permits an MAO assignee to sue medical providers rather than a primary plan.
- Whether CMS regulations could expand the MSP Act's private cause of action to permit suits against medical providers.
Holdings
- MSPA had standing because FHCP suffered a concrete economic injury when reimbursement was delayed for seven months, and FHCP validly assigned the claim through La Ley to MSPA.
- The anti-assignment clause did not bar assignment of FHCP's MSP Act claim because the clause prohibited assignment of the Agreement, while FHCP assigned a separate statutory claim rather than contractual rights under the Agreement.
- The MSP Act's private cause of action permits suit only against a primary plan that fails to provide primary payment or appropriate reimbursement; it does not permit a private plaintiff to sue medical providers that are not primary plans.
- The MSP Act's cross-reference to paragraphs (1) and (2)(A), including the cross-reference structure involving paragraph (2)(B), does not expand the private cause of action to cover medical providers or other statutory violations.
Key quotations
“The inability to have and use money to which a party is entitled is a concrete injury.” (918 F.3d at 1319)
“On its face, the text is clear: plaintiffs can only sue primary plans when they fail to pay.” (918 F.3d at 1324)
“The private cause of action only permits MSPA to sue primary plans.” (918 F.3d at 1329)
Factual background
An enrollee of Florida Healthcare Plus, a Medicare Advantage Organization, was treated at St. Mary's Medical Center after a car accident. Allstate was the primary payer and FHCP was the secondary payer, but St. Mary's billed both insurers for the same treatment and both paid. St. Mary's later reimbursed FHCP approximately $286, about seven months after FHCP's payment. FHCP assigned its MSP Act claims to La Ley Recovery Systems, which assigned them to MSPA Claims 1.
Procedural history
Florida Healthcare Plus, Inc., a Medicare Advantage Organization, paid medical expenses for an enrollee after St. Mary's billed both the primary insurer and FHCP. St. Mary's later reimbursed FHCP approximately $286, and FHCP assigned its Medicare Secondary Payer Act claims through La Ley Recovery Systems to MSPA Claims 1. MSPA sued Tenet and St. Mary's, but the district court granted the defendants' motion to dismiss. The Eleventh Circuit affirmed.