Attorney Bryan Schefman Wins in US Court of Appeals July 16, 2014: Bloomfield Hills, Michigan, United States Court of Appeals for the 6th Circuit

Attorney Bryan Schefman achieved a confirmation of the right of medical providers to seek double damages under the Medicare Secondary Payor (MSP”) act where a no-fault insurer has denied PIP benefits to a Medicare eligible insured and the provider has sought a “conditional payment” under the MSP.

The Court of Appeals held that a medical provider is not required to allege and prove that the non-group health plan made its coverage decision on the basis of Medicare eligibility, interpreting language from 42 USC 1395y in favor of the Plaintiff, so that the only criteria to pursue and MSP claim is that Medicare has paid where another primary plan is liable.

Representing a local neurosurgical provider group in Southeast Michigan, Michigan Spine and Brain Surgeons, PLC, Mr. Schefman sought to enforce his client’s to payment under no-fault insurance issued to the insured and filed suit in the Michigan state courts. The Defendant, State Farm Insurance Company removed the action to the Federal District Court, and filed its Motion for Summary Disposition asserting that the strict language of the MSP required that the Plaintiff must allege and prove that the coverage decision was based on Medicare eligibility, and that without that, Plaintiff’s claim must fail. The lower court initially ruled in favor of Mr.Schefman’s client, and then on Motion for Reconsideration, granted State Farm’s motion. The Court of Appeals reversed and remanded, clarifying the right of medical providers to seek recovery under the MSP, entirely rejecting the argument of State Farm, guided by the legislative history and the governing regulations promulgated pursuant to that act, and the brief filed by Mr. Schefman.

“There is now no question about a medical provider’s right to seek full charges as well as double damages under the MSP, and in this climate, where no-fault insurers are denying more and more invoices for medical services, the MSP is an essential