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CIGA Win Assists Medicare Reimbursement Negotiations

In January of this year, the U.S. District Court for the Central District of California provided relief to the California Insurance Guarantee Association (CIGA) from Medicare demands that CIGA pay full invoices of provider charges, regardless of applicability to the referenced case.

In the case, CIGA argued that Medicare included not only “items or services” related to a medical condition covered by a member insurer’s policy, but also items or services related to the injury.  In an example cited in the case decision, a workers’ compensation policy covered medical costs for leg and back injuries caused by a slip and fall accident, however several charges also contained codes relating to diabetes, insulin use, and bereavement.

In a follow-up decision in May, the court also said that CIGA was entitled to a decision eliminating the Medicare reimbursement demands, as well as a statement that CMS’s “interpretation of the MSP statute with respect to reimbursement of conditional payments is unlawful.”

It is recommended that all claim professionals’ review CMS’s demand letters with very close scrutiny to be sure that the items listed are correctly associated with the case.  Utilizing our award winning RiskPro technology and data warehouses, our analysts are very skilled at verifying, negotiating and eliminating unassociated charges.  If any assistance is required in this regard, please feel free to contact us at This email address is being protected from spambots. You need JavaScript enabled to view it..

For a full reading of the case for background information, please click here >>

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