Case Affirms CMS Right to Conditional Payment Reimbursement

On July 11, 2016, the United States District Court for the Eastern District of New York provided an opinion for Sexton v. Medicare. This opinion is important to all adjusters and practitioners administering workers’ compensation, liability, no-fault, or employer group health insurance.

The Court granted the Secretary of the United States Department of Health and Human Services (HHS) motion to dismiss the case due to a lack subject matter jurisdiction. In its opinion, the Court said that Medicare’s right of action to recover overpayments from primary payers accrues "as soon as it learns that payment has been made or could be made under workers' compensation, any liability or no-fault insurance, or an employer group health plan," 42 C.F.R. § 411.24(b) (emphasis added); see also 42 U.S.C. § 1395y(b)(2)(B)(iii), CMS's right of action against beneficiaries only accrues after the beneficiary has received a primary payment. See 42 C.F.R. § 411.24(g)”.

For the full case opinion, please click here >>