MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co.

43 F.4th 1259
Court of Appeals for the Eleventh Circuit·Decided August 10, 2022·No. 21-11135·Published·Cited by 9 cases

Opinion

[PUBLISH]

In the

United States Court of Appeals For the Eleventh Circuit

No. 21-11135

MSPA CLAIMS 1, LLC, Plaintiff-Appellant,

versus TOWER HILL PRIME INSURANCE CO,

Defendant-Appellee,

TOWER HILL CLAIMS SERVICE, LLC,

Defendant.

2 Opinion of the Court 21-11135

Appeal from the United States District Court for the Northern District of Florida D.C. Docket No. 1:18-cv-00157-AW-GRJ

Before NEWSOM, TJOFLAT, and HULL, Circuit Judges. NEWSOM, Circuit Judge:

MSPA Claims 1 LLC—the assignee of a now-defunct Medicare Advantage Organization—sued Tower Hill Prime Insurance Company to recover a reimbursable payment. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely. We affirm.

I

A

This case centers on the Medicare Secondary Payer Act, which—and this is hardly an outlier sentiment—is “notoriously complex.” Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229, 1240 (11th Cir. 2016) (Pryor, J., dissenting). Given that notorious complexity, we’ll set the table with a remedial course on the Act’s operation.

Congress created Medicare to provide insurance to those over the age of 65. See MSPA Claims 1, LLC v. Kingsway Amigo Ins. Co., 950 F.3d 764, 767 (11th Cir. 2020). Oftentimes, though, it 21-11135 Opinion of the Court 3

turns out that more than one insurer may be liable for a Medicare beneficiary’s medical expenses. For example, a car-accident victim might be entitled to recover medical expenses both from her own Medicare provider and from the other driver’s auto-insurance company . See MSPA Claims 1, LLC v. Tenet Fla., Inc., 918 F.3d 1312, 1316 (11th Cir. 2019). Originally, in such instances, Medicare was the “primary” payer—meaning that it paid first—and private insurers were “secondary” payers—meaning that they covered only those expenses that remained after Medicare had paid. Id.

That changed in 1980. In an effort to cut Medicare costs, Congress “inverted that system” by passing the Medicare Secondary Payer Act. Humana, 832 F.3d at 1234 (quotation omitted). Now, private insurers serve as the primary payers. See id. That leaves Medicare—or in some instances, as we’ll explain, a “Medicare Advantage Organization”—as the secondary payer, or the payer “of last resort, available only if no private insurer [is] liable.” Id.

The Medicare Secondary Payer Act also accounts for what happens when the primary payer “has not made or cannot reasonably be expected to” pay for treatment “promptly.” 42 U.S.C. § 1395y(b)(2)(B)(i). In those instances, the secondary payer “may make” the payment, “conditioned on reimbursement.” Id. The primary payer “shall reimburse” the secondary payer if it “has or had a responsibility to make payment with respect to such item or service.” Id. § 1395y(b)(2)(B)(ii). If the primary payer fails to do so, 4 Opinion of the Court 21-11135

the secondary payer can sue for double damages. See id. §§ 1395y(b)(2)(B)(iii), 1395y(b)(3)(A).

Separately, Congress passed Medicare Part C—the Medicare Advantage program—in 1997. See Pub. L. No. 105-33, 111 Stat. 251, 276 (1997) (codified as amended at 42 U.S.C. § 1395w-21). That legislation, among other things, created Medicare Advantage Organizations—private insurance companies providing Medicare benefits in exchange for fixed fees from the Centers for Medicare and Medicaid Services—and enabled those “MAOs” to act as secondary payers under the Medicare Secondary Payer Act. See Kingsway , 950 F.3d at 768. Accordingly, an MAO, like Medicare, may “sue a primary plan that fails to reimburse [its] secondary payment .” Humana, 832 F.3d at 1238.

But while they possess the same statutory right to seek reimbursement , the Medicare Secondary Payer Act provides distinct causes of action for private and government actors. Thus, “unlike Medicare,” when an MAO sues, it “must rely” on the Medicare Secondary Payer Act’s so-called “private cause of action,” which Congress added to the legislation in 1986, and which is found at 42 U.S.C. § 1395y(b)(3)(A). Tenet, 918 F.3d at 1317; see also Pub. L. No. 99-509, 100 Stat. 1874, 2011 (1986) (codified as amended at 42 U.S.C. § 1395y(b)(3)(A)). It “cannot use the separate government cause of action,” found at 42 U.S.C. § 1395y(b)(2)(B)(iii). Tenet, 918 F.3d at 1317. And, importantly for our purposes, unlike the government cause of action—which contains a three-year statute of limitations—the private cause of action does not specify a 21-11135 Opinion of the Court 5

limitations period. Compare 42 U.S.C. § 1395y(b)(2)(B)(ii), with id. § 1395y(b)(3)(A). As we’ll explain, that’s where the rubber meets the road in this case: Because MSPA Claims 1 sued under the private cause of action, it isn’t clear what the applicable limitations period is or, consequently, whether its claim was timely filed.

B

Now, the facts and procedural history of this case. In 2012, D.L. was attacked by her neighbor’s dog. At the time, D.L. was a Medicare Part C beneficiary enrolled in a Medicare Advantage Program that was administered by Florida Healthcare Plus—a now- defunct MAO. As a result of D.L.’s injuries, Florida Healthcare paid her medical providers $8,146.09.

D.L.’s neighbor held a liability-insurance policy with Tower Hill. Tower Hill entered into a settlement agreement with D.L. in 2012, agreeing to pay her $25,000 in exchange for releasing it from liability. Tower Hill reported the settlement to the Centers for Medicare and Medicaid Services, but it didn’t reimburse Florida Healthcare.

MSPA Claims 1 is Florida Healthcare’s assignee and, therefore , holds the right to any claim that Florida Healthcare might have against Tower Hill to recover the payments made for D.L.’s medical expenses. In 2015, MSPA Claims 1 learned of the possibility of a claim against Tower Hill and it issued a Notice of Lien letter demanding payment “[i]f Medical Payment or other applicable insurance coverage exists.” Tower Hill responded, advising MSPA 6 Opinion of the Court 21-11135

Claims 1 that the claim “was settled on 6/22/12.” That was the first time MSPA Claims 1 had been directly informed of the settlement . MSPA Claims 1 issued a second demand letter in 2018, but Tower Hill never reimbursed it for any payments.

MSPA Claims 1 filed the lawsuit that underlies this appeal on August 17, 2018. In particular, MSPA Claims 1 asserted that Tower Hill caused it (and other similarly situated entities) financial harm when Tower Hill, as a primary payer, failed to pay statutorily required reimbursements. MSPA Claims 1 alleged a claim under the Medicare Secondary Payer Act’s private cause of action, see 42 U.S.C. § 1395y(b)(3)(A), and for breach of contract. On Tower Hill’s motion, the district court dismissed MSPA Claims 1’s breachof -contract count for failure to state a claim.

Following the partial dismissal, the parties submitted dueling summary-judgment motions on MSPA Claims 1’s secondarypayer claim. Tower Hill asserted that it was entitled to summary judgment because MSPA Claims 1’s lawsuit was filed “over six years after [the Centers for Medicare and Medicaid Services] received notice of this claim” in 2012, and was therefore “barred by the three-year statute of limitations” found in the government cause of action, whose limitations period it contended applied to this suit. Although it agreed that the limitations period from the government cause of action applied, MSPA Claims 1 argued that the three-year limitations period begins to run only when “a party is notified of a settlement”—which it insisted occurred, at the 21-11135 Opinion of the Court 7

earliest, in 2015. Accordingly, it contended that it had filed its suit “within the three-year notice-based statute of limitations.”

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MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co., 43 F.4th 1259 (11th Cir. 2022).

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