Oberjuerge Obtains Successful Medicare Trial Decision

In the workers’ compensation and personal injury fields there has been substantial debate in recent years concerning Medicare Set Asides and the powers of Medicare (CMS) to pursue claims against individuals, employers, and insurance carriers where they believe the parties did not adequately consider Medicare’s interest. The present case concerned an accepted workers’ compensation injury claim in which the worker passed away from nonindustrial causes prior to settlement or the use of an MSA. CMS subsequently contacted the self insured employer contending that medical benefits providing during the worker’s life by CMS should have been the responsibility of the workers’ compensation benefit administrator.

EPS was contacted by a permissibly self-insured employer after they received notice that CMS was asserting a conditional payment lien and in fact had referred the alleged debt to the United States Treasury Department for collection. In such scenarios CMS asserts it is a “secondary payor” and the primary payor of medical benefits must be the workers’ compensation employer or insurance carrier. Such action is usually documented via Notice of Conditional Payment Lien asserted by CMS.

Upon taking over representation of the employer, EPS appealed the adverse determination of CMS and its contractor Maximus. Following administrative appeals in which CMS/Maximus maintained it had the right to collect the alleged debt with interest, EPS requested a hearing before the Office of Medicare Hearings and Appeals (OMHA).

Following an adjudicatory hearing on September 28, 2021 involving the submission of documentary evidence and testimony from the claims examiner, EPS Partner Alex Oberjuerge submitted the case for decision with the Administrative Law Judge who subsequently issued a “Fully Favorable” Decision concluding the employer was not liable for any of the monies contained in the Medicare Conditional Payment lien.

EPS prepares Medicare analyses and CMS submissions for clients, and is pleased to have successfully defensed an effort from CMS to shift liability onto the workers’ compensation benefit provider employer. Portion of ALJ Decision below.

EPS Medicare Decision

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9th Circuit Victory for EPS

9th Circuit

The very questions of injury and proof were before the 9th Circuit Court of Appeals in a recently argued LHWCA matter.    The matter arose as an orthopedic and pulmonary cumulative trauma claim of a decades long maritime pile driver asserted against his last maritime employer.  The matter was tried over multiple days by Barry Ponticello, with an ALJ finding of no orthopedic or pulmonary injury.  This decision was affirmed by the BRB.

At the 9th Circuit, the Claimant sought an alternative standard of proof in multiple employer cases, as well as differing occupational disease injury standards.  Briefing opposing these theories was undertaken by Renee St.Clair and Mr. Ponticello, with Mr. Ponticello arguing the matter before the 3 judge appellate panel, who affirmed the Trial Decision.

06-11-18-KellJa-Memorandum Affirming -Final Disposition

 

EPS “Subro” Win Ordered Published: (Duncan v Wal-Mart)

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In an appellate matter of significant importance to California carriers and employers, the EPS workers’ compensation subrogation team obtained a victory at the Court of Appeal, Fourth Appellate District.  The Court of Appeal issued a decision reversing the Trial Judge, and vindicating the benefit provider’s rights under Labor Code Section 3856.

The Decision can be read here:  http://www.courts.ca.gov/opinions/documents/G054220.PDF

 

 

“Subro” matter argued before the 4th District Court of Appeal

court of appealIn  a workers’ compensation subrogation matter involving post Trial division of judgment proceeds and the application and interpretation of Labor Code Section 3856, EPS appeared before the 4th District Court of Appeal, Division Three in Santa Ana.   Barry Ponticello, a veteran of California Supreme Court, California Appellate Court and U.S. Circuit Court of Appeals for the 9th Circuit oral arguments, argued on behalf of the benefit provider.