CMS WCMSA Against CIGA Turned Away By Federal Court

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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
Supreme Court CMS WCMSA Buiding
Wikimedia Commons – Daderot

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.

Gavel And Judge Chair CMS WCMSA In Court
StockUnlimited

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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    thinking, article is nice, thats why i have read it completely

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James Moore

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

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