Court Follows Sixth’s Circuit Decision that Providers May Assert a Private Cause of Action

In Michigan Spine & Brain Surgeons v. State Farm Mutual Automobile Insurance Co., No. 12-CV-11329, 2013 U.S. Dist. LEXIS 17721 (E.D. Mich. Feb. 11, 2013), State Farm denied coverage of medical treatment provided by Michigan Spine on the basis that the treatment was related to preexisting conditions of the individual insured, and unrelated to the accident at issue.  As a result, Medicare paid for those medical expenses.  Michigan Spine filed a claim for recovery against State Farm, asserting that it had a private cause of action for double damages under the Medicare Secondary Payer Act.  In response, State Farm argued that Michigan Spine had no standing to bring a claim under the Medicare Secondary Payer Act because no court had determined that State Farm was liable for the medical services in question.

The Court acknowledged that the underlying issue was addressed by the Sixth Circuit in Bio-Medical Applications of Tennessee., Inc. v. Central States Health & Welfare Fund, 656 F.3d 277 (6th Cir. 2011).  In that case, the Sixth Circuit held that “a healthcare provider need not previously 'demonstrate' a private insurer's responsibility to pay before bringing a lawsuit under the Act's private cause of action.” Mich. Spine & Brain Surgeons, 2013 U.S. Dist. LEXIS 17721, at *15 (citing Bio-Medical Applications of Tenn., Inc., 656 F.3d at 278-79). The district court followed the Sixth’s Circuit decision in Bio-Medical Applications of Tenn., Inc., and accordingly, denied State Farm’s Motion to Dismiss.