Medicare Liens Are Limited

Two weeks ago, a California District Court ruled that Medicare can only seek reimbursement for items and services related to the underlying claim. Logical? Sure. But there’s more to it! First, the Court took on Medicare’s combination of ICD-9 or ICD-10 codes into one payment. Second, the Court reminded us all that Medicare’s claim is limited to the same claim that a Plaintiff can make.

The case discussed is California Insurance Guarantee Association v. Burwell (“CIGA”). As of today it does not have a federal reporter citation. It can be found at 2017 US Dist. LEXIS 1681 (January 5, 2017).

Combination of ICD Codes

The CIGA Court stated “The Court is unconvinced that CIGA has a ‘responsibility to make payment’ for a treatment not covered by its policy just because that treatment is lumped together with other covered treatments on a line-item charge.” (Emphasis added). The key point is that the Court will not allow Medicare to call a payment “related” simply because one of many ICD codes is related to the sued-for injuries. The Court rejected Medicare’s process of combining claims.

The Lien Should Follow the Underlying Claim

Next, the Court discussed how to define “related” and “unrelated” payments. “Whether a compensation carrier has a ‘responsibility to make payment’ with respect to an item or service is generally a matter of state law.” (Emphasis added). This statement defines Medicare’s right to reimbursement – the Medicare Lien – as being equal to that which the plaintiff can claim. For example, if a Wrongful Death action in your state does not include medicals, and your claim is strictly for wrongful death, then Medicare cannot have any reimbursement.

This rule is clearly stated in the Medicare Secondary Payer Act:

[A] primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate Trust Fund for any payment made by the Secretary under this subchapter with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service. (Emphasis Added).

While this decision is simply that of a US District Court (and neither a Circuit or the Supreme Court), we have seen Medicare adjust its policies for similarly situated cases in the past. Even if a higher court does not take on the case, this is just another of many methods we can use to control and reduce Medicare liens.

If you need help with lien resolution, the simplest option is to utilize a lien resolution service. For help with Medicare Liens, Medicaid Liens and any other Health Insurance Lien , please contact us at (844) MED LIEN or (844) 633-5436.

Ryan Weiner

Chief Operating Officer

[email protected]


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