This document provides an overview of Medicare liens, including liens from Medicare Advantage plans. It discusses that Medicare Advantage plans have the same rights to recover conditional payments as traditional Medicare, including the right to double damages if not reimbursed. It also summarizes the PAID Act, which aims to provide more information to responsible reporting entities about a beneficiary's enrollment in Medicare Advantage and Part D plans to help identify potential liens. The document emphasizes best practices for plaintiff attorneys to identify potential hidden Medicare liens early in a case.

1. H i d d e n M e d i c a r e
A d v a n t a g e L i e n s

2. Teresa S. Kenyon, Esq.
Director of Lien Resolution
Services
TERESA S. KENYON, ESQ.
Teresa Kenyon is the Director of Lien Resolution
Services for Synergy Settlement Services. She is a
California and Kentucky licensed attorney. Prior to
joining Synergy, Teresa worked with The Rawlings
Company on behalf of health insurance carriers
seeking reimbursement.
Teresa and her team provide invaluable assistance to
plaintiff attorneys by handling all types of health liens.
Her growing team has over 300 years of experience
in battling liens and passionately fighting for the
injured party.

3. Liens We Handle
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4. Today’s Agenda
▪ Traditional Medicare
▪ Medicare Part C
▪ Medicare Advantage Liens
▪ Procurement Reduction
▪ Recovery Vendors for Medicare Advantage Plans
▪ Double Damages
▪ Best Practices
▪ PAID Act

5. Medicare as Secondary Payer
▪ Medicare may not pay for a beneficiary's medical expenses when payment “has been
made or can reasonably be expected to be made under
▪ a workers’ compensation plan,
▪ an automobile or liability insurance policy or plan (including a self-insured plan), or
▪ under no-fault insurance.” 42 U.S.C.§ 1395 y(b)2(a)
▪ If responsibility for the medical expenses incurred is in dispute and other insurance will
not pay promptly, the provider, physician, or other supplier may bill Medicare as the
primary payer.
▪ If the item or service is reimbursable under Medicare rules, Medicare may pay conditionally, subject to later
recovery if there is a subsequent settlement, judgment, award, or other payment.

6. Parts of Medicare
▪ Part A (Hospital Insurance)
▪ Part B (Medical Insurance)
▪ Part C (Medicare Advantage
HMO/PPO – private health insurance
companies)
▪ Part D (RX)
▪ In 2022, 42% of all Medicare
beneficiaries – more than 26 million
people out of 67.7 million Medicare
beneficiaries overall – are enrolled in
Medicare Advantage plans; this rate
has steadily increased over time since
the early 2000s

7. Medicare Advantage Plans – Part C
▪ President Clinton signed Medicare + Choice into law in 1997
▪ Medicare Modernization Act of 2003 changed the name to Medicare
Advantage
▪ These are not private insurance plans rather they are funded from the
same trust funds that support traditional Medicare
▪ Part C plans include all of Part A and B coverage plus more
▪ Medicare Advantage plan governed by the Medicare Act
▪ Same rights and responsibilities
▪ Double damages if not reimbursed

8. • United Healthcare and
Humana together
account for 45 percent
of all Medicare
Advantage enrollees
nationwide.
• BCBS affiliates (including
Anthem BCBS plans)
account for another 14
percent of enrollment in
2021.
• Four firms (CVS Health,
Kaiser Permanente,
Centene, and Cigna)
account for another 23
percent of enrollment in
2021.

9. M e d i c a r e A d v a n t a g e
L i e n s

10. Procurement Cost Reduction
▪ Medicare Advantage Plans
use the Medicare Secondary
Payer statute as the basis for
their claim to reimbursement.
42 C.F.R. § 422.108(f).
▪ Accordingly, their repayment
formulas should be the same as
Medicare under 411.37 (c) and (d)
which requires a procurement
cost reduction.

11. Recovery Vendors
▪ The Big Recovery Players
▪ Optum
▪ Equian
▪ Conduent
▪ Rawlings
▪ BCBS, Humana (internal)
▪ Various defense firms
▪ Highly trained
▪ Narrow arguments
▪ Form Letters
▪ Limited Authority to Reduce
▪ Incentivized by Bonus, Reprimand
▪ Various Lien Types
▪ ERISA, Medicare Advantage, Supplement,
FEHBA, Medicaid MCO/HMO

12. 15% Reduction

13. Rawlings Position
I have provided you with a copy of the plan language, the
CONTRACTED language that CMS has approved, that your
client signed up for, that directly address the recovery and
reimbursement rights. The Plan language clearly points out
the plans rights of recovery that states we do not have to
reduce for cost and fees. I would argue to please present
your legal support that the health plans recovery rights are
governed by the Medicare statue and not by the language
that was presented to your office and was approved by
CMS. As with all health plans, the language is a contract that
details the rights the plan has for recovery.
In an effort to save everyone time and money, I would be
willing to take an offer of $29,000.00 to my client to get the
lien resolved before we start down the path headed for
litigation. Please also note to your client that when this gets
litigated, we will seek our full attorney fees as well.
Email

14. The Policy Language
• Reference to Medicare Statute
• Standard Health Insurance Contract Language

15. Double Damage if NOT Paid
▪ 42 U.S.C. § 1395y(b)(2)(B)(iii)
“In order to recover payment made under this subchapter for an item or service, the United States may bring an action
against any or all entities that are or were required or responsible… to make payment with respect to the same item or
service… under a primary plan. The United States may… collect double damages against any such entity. In addition, the
United States may recover under this clause from any entity that has received payment from a primary plan or from
the proceeds of a primary plan’s payment to any entity.”
▪ 42 C.F.R. §411.24(g)
“CMS has a right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician,
attorney, State agency or private insurer that has received a primary payment.”

16. Private Cause of Action
42 C.F.R. §422.108(f) extends the private cause of action to
Medicare Advantage Plans:​
▪ “MAOs will exercise the same rights to recover from a primary
plan, entity, or individual that the Secretary exercises under the
MSP regulations in subparts B through D of part 411 of this chapter”

17. ▪ CMS Memorandum (12/2011) Indicated MAOs have same rights to recover as Medicare
itself.
▪ In Re Avandia (3rd Cir. 2012)​ Medicare Advantage Plan could maintain private cause of
action to recover conditional payments made on behalf of beneficiary.
▪ Humana v Paris Blank LLP (4th Cir.2016) Court allowed Medicare Advantage plan’s suit to
proceed under a private cause of action against Plaintiff attorneys that fail to reimburse
conditional payments.
▪ Humana Medical Plan v. Western Heritage (11th Cir. 2016) Humana entitled to double their
lien amount against Western Heritage.
▪ “A primary payer must reimburse Medicare even though it has already reimbursed the
beneficiary or other party. 42 C.F.R.§411.24 (i)(1)

18. Best Practices to Identify Hidden Lien
▪ Begin investigation early
▪ Request copies of the Medicare beneficiary’s health insurance cards
at time of case intake
▪ Request updated information during life of claim (coverages change)
▪ Review billing statements in medical records
▪ Review billing statements in pharmacy records
▪ Confirm beneficiary’s enrollment through MyMedicare.gov

19. Medicare.Gov Report

20. Medicare.Gov Report

21. P A I D A c t
P r o v i d e A c c u r a t e
I n f o r m a t i o n D i r e c t l y
A c t

22. PAID Act
▪ In 2020, the Provide Accurate Information Directly Act (PAID Act) was
passed to help:
▪ Non Group Health Plans (NGHP) Responsible Reporting Entities (RREs) better
coordinate benefits by providing additional beneficiary enrollment information.
▪ NGHP - include liability insurers (including self-insured entities), no-fault insurers, and
workers' compensation entities
▪ RREs – the party responsible for funding a claim payment to a Medicare beneficiary
▪ With this Act, RREs will now receive Part C (Medicare Advantage Plan)
and Part D (Medicare prescription drug coverage) enrollment information
▪ For the past 3 years (up to 12 instances)
▪ As well as the most recent Part A and Part B entitlement dates

23. How PAID Act Should Help
▪ Currently, Medicare portal will only relay whether or not traditional
Medicare has paid claims or not
▪ Does not give insight on Medicare Advantage Plans or RX
▪ PAID Act process should uncover the hidden Medicare Advantage Plans
(and RX) that could seek double damages from Plaintiff Counsel
▪ To defense
▪ Hopefully, that allows the Plaintiff Counsel to be brought into the know

25. Learn more today Call us at (877) 242-0222
Or visit synergysettlements.com