935 F.3d 521
6th Cir.2019Background
- In 2014 Osborne (a Medicare beneficiary) fractured his arm at a Metro Nashville facility and later obtained a Tennessee state-court judgment against Metro Nashville for medical expenses and other damages; the judgment survived appeal.
- Before the state judgment, Medicare made conditional payments for Osborne’s medical care totaling at least $9,453.09 because Metro Nashville did not pay those bills at the time.
- Osborne alleges Metro Nashville has not reimbursed Medicare for those conditional payments and has not satisfied the state-court judgment, forcing him to pay copays/deductibles and incur litigation costs.
- Osborne sued in federal court under the Medicare Secondary Payer Act (MSPA), 42 U.S.C. § 1395y(b), seeking reimbursement and double damages under § 1395y(b)(3)(A).
- The district court dismissed, holding Osborne lacked a private cause of action under the MSPA against a tortfeasor and also lacked Article III standing to pursue Medicare’s conditional-payment claim; the Sixth Circuit affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether MSPA provides a private right for a Medicare beneficiary to sue a tortfeasor for reimbursement/double damages | Osborne: MSPA’s private cause of action covers "primary plans," which include tortfeasors after the 2003 amendments, so he can sue for double damages | Metro Nashville: MSPA (esp. the 2003 amendments and the "demonstrated responsibility" provision) was intended to let Medicare, not private parties, sue tortfeasors; private suits would make MSPA a super-judgment enforcement tool | Court: MSPA does not permit a private cause of action by a Medicare beneficiary against a tortfeasor; affirmed dismissal |
| Whether Osborne has Article III standing to pursue Medicare’s conditional-payment reimbursement | Osborne: Medicare’s financial injury is attributable to him and he suffered out-of-pocket copays and costs | Metro Nashville: Medicare’s injury is separate; Osborne cannot assert Medicare’s claim; his alleged individual injuries are conclusory or redressed by state judgment | Court: Osborne lacks standing to sue for Medicare’s conditional payments and his asserted individual harms were insufficiently pleaded |
| Whether the 2003 MSPA amendments (including "demonstrated responsibility") change the private cause of action scope | Osborne: Amendments expanded "primary plan" to include tortfeasors, enabling private suits | Metro Nashville: Amendments intended to enable Medicare recovery against tortfeasors, not private litigants | Court: Sixth Circuit precedent (Bio-Medical) persuasively interprets amendments as permitting Medicare-only suits against tortfeasors |
| Whether use of MSPA here would improperly convert it into a super-judgment enforcement mechanism | Osborne: MSPA double-damages remedy is available regardless | Metro Nashville: Allowing a second federal MSPA suit after a state judgment would convert MSPA into a super-judgment device | Court: Agrees that permitting Osborne’s suit would risk transforming MSPA into a super-judgment enforcement mechanism; supports denial |
Key Cases Cited
- Bio-Medical Applications of Tenn., Inc. v. Cent. States Se. & Sw. Areas Health & Welfare Fund, 656 F.3d 277 (6th Cir. 2011) (extensive analysis concluding 2003 MSPA amendments allow Medicare, not private parties, to sue tortfeasors)
- Keys v. Humana, Inc., 684 F.3d 605 (6th Cir. 2012) (standard of review for Rule 12(b)(6) dismissal)
- Crugher v. Prelesnik, 761 F.3d 610 (6th Cir. 2014) (pleading standard and construing complaints in plaintiff’s favor)
- Bell Atl. Corp. v. Twombly, 550 U.S. 544 (2007) (plausibility pleading standard)
- Lewis v. Cont'l Bank Corp., 494 U.S. 472 (1990) (attorney’s fees alone do not create Article III case or controversy)
- Mich. Spine & Brain Surgeons, PLLC v. State Farm Mut. Auto. Ins. Co., 758 F.3d 787 (6th Cir. 2014) (distinguishing aspects of MSPA private cause of action applicability)
- Glover v. Liggett Grp., Inc., 459 F.3d 1304 (11th Cir. 2006) (interpretation of MSPA expansion to include entities carrying their own risk)