HDM Corp. v. United States

69 Fed. Cl. 243, 2005 U.S. Claims LEXIS 372, 2005 WL 3695761
CourtUnited States Court of Federal Claims
DecidedNovember 30, 2005
DocketNo. 04-694 C
StatusPublished
Cited by10 cases

This text of 69 Fed. Cl. 243 (HDM Corp. v. United States) is published on Counsel Stack Legal Research, covering United States Court of Federal Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
HDM Corp. v. United States, 69 Fed. Cl. 243, 2005 U.S. Claims LEXIS 372, 2005 WL 3695761 (uscfc 2005).

Opinion

OPINION AND ORDER

GEORGE W. MILLER, Judge.

This matter is before the Court on plaintiffs Motion for Partial Summary Judgment on the Administrative Record pursuant to Rule 56.1 of the Rules of the Court of Federal Claims (“RCFC”), plaintiffs Motion for Preliminary Injunction pursuant to RCFC 65(a), defendant’s Cross-Motion for Partial Judgment Upon the Administrative Record pursuant to RCFC 56.1, and defendant-inter-venor’s Cross-Motion for Partial Summary Judgment on Counts II and III. The Court heard oral argument on the motions on October 28, 2005. At the conclusion of the argument, the Court announced its decision and summarized its reasoning orally from the bench. The Court stated that a written opinion would follow. For the reasons discussed below, plaintiffs Motion for Partial Summary Judgment on the Administrative Record is DENIED, and defendant’s Cross-Motion for Partial Judgment Upon the Administrative Record and defendant-intervenor’s Cross-Motion for Partial Summary Judgment on Counts II and III (treated as a motion for judgment on the administrative record as to Counts II and III) are GRANTED. Plaintiffs Motion for Preliminary Injunction is DENIED as moot.

BACKGROUND2

Medicare is a nationwide, federal insurance program for persons 65 years of age or over and certain younger disabled persons. AR Tab 14 at 772, § 1.1., The Medicare Program.3 The Centers for Medicare and Medicaid Services (“CMS”) is an agency of defendant United States within the Department of Health and Human Services (“HHS”) responsible for administration of the Medicare Program, including formulation and promulgation of Medicare Program policy and guidance, contract execution, and operation and management.4 AR Tab 14 at 774, § 1.1, The Medicare Program. In 1999, CMS entered into a Coordination of Benefits (“COB”) contract with defendant-intervenor Group Health Incorporated (“GHI”) to ensure that Medicare dollars were paid correctly and to simplify the coordination of payments between Medicare and private insurers. Decl. of Harry Gamble ¶ 2. In 2003, CMS issued a modification to the COB contract. Id. ¶ 19. Plaintiff HDM Corp. (“HDM”), a company that serves as a clearinghouse for Medicare claims, alleges that this modification was issued without competitive bidding in violation of the Competition in Contracting Act (“CICA”), 41 U.S.C. § 253 (2000). Pl.’s Br. in Support of Mot. for Summ. J. at 1; Pl.’s Statement of Facts ¶ 2.

I. Overview of Medicare Claims Processing

To explain the contract modification at issue in this litigation, it is necessary to provide substantial background information regarding Medicare claims processing and the changes to this process under the COB contract. The process is highly technical and complicated, and involves many terms of art not within the knowledge of most lay persons.

Medicare does not typically pay for all of the health care costs of its beneficiaries, and therefore, many of these beneficiaries have additional health insurance. Decl. of Peter Moore ¶ 4. In addition, situations arise where a third party’s insurance, rather than Medicare, bears primary responsibility for paying for a Medicare beneficiary’s health care costs. Id. For example, if a beneficiary is in [246]*246an accident caused by a third party, that third party’s insurance, rather than Medicare, may be primarily responsible for the beneficiary’s health care costs resulting from the accident. Id. Therefore, when a beneficiary incurs health care costs, it is necessary to determine which payer is primarily responsible for these costs to arrange for payment to the health care provider. Id. ¶ 5.

The process of determining which entity is responsible to pay benefits and arranging for the payment of benefits by the correct payer is known as coordination of benefits. Id. The coordination of benefits process encompasses two claims-payment situations: (1) Medicare secondary payer (“MSP”), where another insurer is the primary payer and Medicare is the secondary payer; and (2) the transfer of Medicare-paid claims to supplemental insurers (“transfer claims”), where Medicare pays first and another insurer pays second. Decl. of Harry Gamble ¶ 3. MSP claims processing encompasses a much more varied and multidimensional set of processes than transfer claims processing, and is not at issue in this litigation. See id.

Historically, the processing of both MSP and transfer claims relied upon claims-processing contractors. Id. ¶ 4. Sections 1816(a), 42 U.S.C. § 1395(h) (2000), and 1842(a), 42 U.S.C. § 1395(u) (2000), of the Social Security Act authorize the Secretary of HHS to enter into contracts with private entities for the purpose of distributing Medicare payments. Id.; AR Tab 14 at 774, § 1.1, The Medicare Program. These private claims contractors are known as Fiscal Intermediaries (“FIs”) and carriers.5 Def.’s Statement of Facts ¶ 3, Decl. of Harry Gamble ¶ 4. In total, HHS entered contracts with 51 separate FIs and carriers that distributed payments for Medicare. Decl. of Harry Gamble ¶ 4.

Prior to the COB contract, when a Medicare beneficiary received medical treatment from a health care provider, the provider would bill the FI or carrier serving the region where the services were provided. Decl. of Harry Gamble ¶ 5. The FI or carrier would send the claim information to a master file, known as the Common Working File (“CWF”) for validation. Id. The CWF determination would be communicated back to the FI or carrier, which would either make payment or generate a notice of denial or non-coverage to the provider. Id. However, if beneficiaries had additional insurance that covered costs that were not covered by Medicare, the additional insurer needed to review the claim, ascertain the portion that Medicare paid, and determine whether it needed to pay the remainder under the terms of its insurance policy. Def.-Intervenor’s Cross-Motion for Summ. J. at 6.

To coordinate benefit payments among Medicare as a primary payer and other insurers as secondary payers, the FIs and carriers negotiated “Trading Partner Agreements” with secondary health insurers. Decl. of Harry Gamble ¶ 6. Under these Trading Partner Agreements, secondary insurers provided FIs and carriers with a list of their insured, known as an eligibility file, and a list of claims selection choices. Id. The FI or carrier would check claims received from providers against a secondary insurer’s eligibility file, and for each match, in exchange for a per-claim fee, would communicate Medicare primary payment information to the secondary insurer, allowing it to determine its liability and make its share of the payment to the provider. Id. The actual transmission of Medicare adjudicated claims data to a secondary supplemental insurer or payer is known as “crossover.”6 Pl.’s Reply to Def. and Def.-Intervenor’s Opposition to HDM’s Mot. For Partial Summ. J. and for Prelim. Inj. (“Pl.’s Reply”) at 3.

[247]*247The system was not without its limitations.

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Cite This Page — Counsel Stack

Bluebook (online)
69 Fed. Cl. 243, 2005 U.S. Claims LEXIS 372, 2005 WL 3695761, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hdm-corp-v-united-states-uscfc-2005.