Bloomfield Hills, MI (PRWEB) July 18, 2014
The Court of Appeals held that a health care provider can use the Medicare Secondary Payer Act’s private cause of action against a non-group health plan (no-fault insurer) that denies coverage for reasons other than Medicare eligibility, interpreting language from 42 USC 1395y and its regulations, so that the only criteria required to pursue an MSP claim against a non-group health plan such as no-fault is that Medicare has paid where another primary plan is liable. Mich. Spine v. State Farm, page 1-2, 8-9, of the Slip Opinion, United State Court of Appeals for the 6th Cir, Case No. 13-2430, Decided July 16, 2014. See also In Re Avandia, 685 F.3d at 363; Manning v. Utilities Mutual Insurance, 254 F.3d 387 (2d Cir. 2001).
Representing a local neurosurgical provider group in Southeast Michigan, Michigan Spine and Brain Surgeons, PLC, Mr. Schefman sought to enforce his client’s right to payment under no-fault insurance issued to the insured/patient arising out of a motor vehicle collision, and filed suit after the claim was denied as injuries not being related to the motor vehicle collision. The Defendant State Farm alleged that because it had not made its coverage decision on the basis of Medicare eligibility, Michigan Spine could use the MSP. The Court of Appeals adopted Mr. Schefman’s argument and upheld the right of medical providers to use the MSP where Medicare has stepped in and paid where a no-fault, non-group health plan is liable.
“There is now no question about a medical provider’s right to seek full charges as well as double damages under the MSP, and in this climate, where no-fault insurers are denying more and more invoices for medical services, leaving Medicare to foot the bill, the MSP is an essential tool.”