It “cannot use the separate government cause of action,” found at 42 U.S.C. Thus, “unlike Medicare,” when an MAO sues, it “must rely” on the Medicare Secondary Payer Act’s so-called “private cause of action,” which Congress added to the legislation in 1986, and which is found at 42 U.S.C. But while they possess the same statutory right to seek reimbursement, the Medicare Secondary Payer Act provides distinct causes of action for private and government actors. Accordingly, an MAO, like Medicare, may “sue a primary plan that fails to reimburse secondary payment.” Humana, 832 F.3d at 1238. That legislation, among other things, created Medicare Advantage Organizations-private insurance companies providing Medicare benefits in exchange for fixed fees from the Centers for Medicare and Medicaid Services-and enabled those “MAOs” to act as secondary payers under the Medicare Secondary Payer Act. Separately, Congress passed Medicare Part C-the Medicare Advantage program-in 1997. If the primary payer fails to do so, USCA11 Case: 21-11135 4 Date Filed: Page: 4 of 18 Opinion of the Court the secondary payer can sue for double damages. The primary payer “shall reimburse” the secondary payer if it “has or had a responsibility to make payment with respect to such item or service.” Id. In those instances, the secondary payer “may make” the payment, “conditioned on reimbursement.” Id. The Medicare Secondary Payer Act also accounts for what happens when the primary payer “has not made or cannot reasonably be expected to” pay for treatment “promptly.” 42 U.S.C. That leaves Medicare-or in some instances, as we’ll explain, a “Medicare Advantage Organization”-as the secondary payer, or the payer “of last resort, available only if no private insurer liable.” Id. Now, private insurers serve as the primary payers. Humana, 832 F.3d at 1234 (quotation omitted). In an effort to cut Medicare costs, Congress “inverted that system” by passing the Medicare Secondary Payer Act. Originally, in such instances, Medicare was the “primary” payer-meaning that it paid first-and private insurers were “secondary” payers-meaning that they covered only those expenses that remained after Medicare had paid. For example, a car-accident victim might be entitled to recover medical expenses both from her own Medicare provider and from the other driver’s auto-insurance company. Oftentimes, though, it USCA11 Case: 21-11135 21-11135 Date Filed: Opinion of the Court Page: 3 of 18 3 turns out that more than one insurer may be liable for a Medicare beneficiary’s medical expenses. Congress created Medicare to provide insurance to those over the age of 65. Given that notorious complexity, we’ll set the table with a remedial course on the Act’s operation. I A This case centers on the Medicare Secondary Payer Act, which-and this is hardly an outlier sentiment-is “notoriously complex.” Humana Med. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely. NEWSOM, Circuit Judge: MSPA Claims 1 LLC-the assignee of a now-defunct Medicare Advantage Organization-sued Tower Hill Prime Insurance Company to recover a reimbursable payment. 1:18-cv-00157-AW-GRJ _ Before NEWSOM, TJOFLAT, and HULL, Circuit Judges. USCA11 Case: 21-11135 2 Date Filed: Page: 2 of 18 Opinion of the Court 21-11135 _ Appeal from the United States District Court for the Northern District of Florida D.C. 21-11135 _ MSPA CLAIMS 1, LLC, Plaintiff-Appellant, versus TOWER HILL PRIME INSURANCE CO, Defendant-Appellee, TOWER HILL CLAIMS SERVICE, LLC, Defendant. USCA11 Case: 21-11135 Date Filed: Page: 1 of 18 In the United States Court of Appeals For the Eleventh Circuit _ No.
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