An emerging area of focus on the Medicare Secondary Payer compliance landscape relates to Medicare Advantage (MA) plans. Interest in this topic has been generated by the claim industry’s heightened sensitivity to Medicare compliance issues in general, and in light of the fact that MA plans are taking a more aggressive posture in the claims context.
Over the past several months, questions concerning MA plans have also been the subject of three important court opinions, including the recent decision of In Re Avandia Marketing, Sales Practices and Products Liability Litigation, Nos. 7-md-01871, 10-6733, 2011 WL 2413488 (D. Pa.,
June 13, 2011) issued by the United States District Court for the Eastern District of Pennsylvania.
A key question concerns whether or not MA plans have reimbursement rights under the Medicare Secondary Payer Statute (MSP)1, or other authority, against primary payers and other parties for accident- related medical treatment provided in relation to workers’ compensation, liability or other injury-based claim2.
As the claims industry currently examines this issue, several important questions arise, such as:
What are MA plans?
How do MA plans fit into the larger Medicare program?
What are the differences between “traditional” Medicare and MA plans?
Do MA plans have reimbursement rights?
If so, what are the nature and extent of these rights?
How have the courts ruled?
Through this article, the author aims to address these questions to assist the reader in better
placing MA plans into a more clear and workable framework.