New Ruling: Court Expands upon Its Recent Ruling Limiting CMS Recovery Rights

The court in CIGA v. Price, 2017 WL 1737717 (C.D. California, May 3, 2017) has expanded upon its prior order limiting Medicare’s conditional payment rights. The case has garnered much industry attention, given its potential impact on the Centers for Medicare & Medicaid Services (CMS) recovery claims. The Case In this action, CIGA challenged CMS’ […]

Breaking: CMS Recovery Practice Ruled Improper under the MSP

In an important new case—CIGA v. Burwell, 2017 WL 58821 (C.D. California, January 5, 2017)—the court ruled that the CMS practice of seeking full reimbursement of a medical provider’s single charge—even where some unsegregated portion of that charge relates to services not covered by a workers’ compensation plan—was improper under the Medicare Secondary Payer Statute […]

Settlement Language Strikes Again
New Case Proves Clear Provisions Are Critical

Settlement language is an important aspect of Medicare Secondary Payer (MSP) claims that demands careful consideration. When settlements fail to address key MSP issues or neglect to reflect payer intentions, there can be trouble ahead. The latest example is from a California case: Karpinski v. Smitty’s Bar, Inc., 2016 WL 1445338 (Cal. Ct. App., April […]

California becomes fifth state to require closed drug formulary for workers’ compensation claims

California Governor Jerry Brown has signed Assembly Bill No. 1124, which mandates that the Division of Workers’ Compensation (DWC) implement a prescription drug formulary by July 1, 2017. The bill, sponsored by Henry Perea (D-Fresno), makes California the fifth state—along with Texas, Oklahoma, Washington, and Ohio—to provide a closed pharmacy formulary for medications prescribed to […]

Impact of Utilization Review on Medicare Set-Asides

Although Utilization Reviews (URs) and Independent Medical Reviews (IMRs) have been used in state jurisdictions for years, insurers have only recently focused on how the Centers for Medicare and Medicaid Services (CMS) treats URs and IMRs when evaluating Medicare Set-Asides (MSAs). Since URs and IMRs can offer significant cost savings, claims examiners are becoming keenly […]