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

43 F.4th 1259
CourtCourt of Appeals for the Eleventh Circuit
DecidedAugust 10, 2022
Docket21-11135
StatusPublished
Cited by9 cases

This text of 43 F.4th 1259 (MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eleventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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

Opinion

USCA11 Case: 21-11135 Date Filed: 08/10/2022 Page: 1 of 18

[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. USCA11 Case: 21-11135 Date Filed: 08/10/2022 Page: 2 of 18

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 Medi- care 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 de- termined 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 USCA11 Case: 21-11135 Date Filed: 08/10/2022 Page: 3 of 18

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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 com- pany. 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 insur- ers 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 Second- ary 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 “Medi- care 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 reason- ably 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, USCA11 Case: 21-11135 Date Filed: 08/10/2022 Page: 4 of 18

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 sec- ondary payers under the Medicare Secondary Payer Act. See King- sway, 950 F.3d at 768. Accordingly, an MAO, like Medicare, may “sue a primary plan that fails to reimburse [its] secondary pay- ment.” Humana, 832 F.3d at 1238. But while they possess the same statutory right to seek re- imbursement, 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 Sec- ondary Payer Act’s so-called “private cause of action,” which Con- gress 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 gov- ernment cause of action—which contains a three-year statute of limitations—the private cause of action does not specify a USCA11 Case: 21-11135 Date Filed: 08/10/2022 Page: 5 of 18

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 pri- vate 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 Pro- gram 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, there- fore, 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 possibil- ity of a claim against Tower Hill and it issued a Notice of Lien letter demanding payment “[i]f Medical Payment or other applicable in- surance coverage exists.” Tower Hill responded, advising MSPA USCA11 Case: 21-11135 Date Filed: 08/10/2022 Page: 6 of 18

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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 settle- ment. 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.

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43 F.4th 1259, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mspa-claims-1-llc-v-tower-hill-prime-insurance-co-ca11-2022.