CMS WCMSA Medicare
A CMS WCMSA is turned away by the Federal Court system partially.
Acronyms are as follows:
- CMS – Center for Medicare Medicaid Services
- WCMSA – Workers Compensation Medicare Set Aside
- CIGA – California Insurance Guarantee Association
The order can be found here.. It is a PDF file. The case is CIGA v Burwell, DHS, and CMS. The case number is 2:15-cv-01113-ODW (FFMx)
The case is one that I recommend at least scanning the order for a few minutes. A large part of the nuts-and-bolts in CMS WCMSA handling can be found in the decision.
Some of the highlights were:
For two of the three demands at issue, CIGA disputed its liability for the charges on several grounds—including that they contained diagnosis codes that were not covered by the underlying workers’ compensation policies.
The Court is also unconvinced that CIGA has a “responsibility to make payment” for a treatment not covered by its policy just because that treatment is lumped together with other covered treatments on a line-item charge.
Defendants argue that because CMS will no longer seek reimbursement for the payments allegedly owed under the three claims, this action is moot and must be dismissed. CIGA responds that Defendants’ conduct does not make it “absolutely clear” that CMS will never again reopen these claims or reapply the offending practice, which means the case is not moot. The Court agrees with CIGA that no part of the case is moot.
The last passage above is very interesting as it seems CMS withdrew part of their case but the judge was concerned they would commence the same allegations in another lawsuit.
This decision came out of a Motion For Summary Judgement by the defendants. This decision may be one to print out and review carefully. I am just paraphrasing the decision for readability and conciseness.
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