Referral of Cases to Regional Office for Possible Government Intervention

10.6 – Referral of Cases to Regional Office for Possible Government Intervention and/or Legal Action (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) The MSP Contractor shall refer the following situations to CMS and/or the appropriate RO: a) Any notice from a court that CMS has been made a party to a lawsuit; or b) Any case involving a lawsuit in which CMS’s claim is at issue. The MSP Contractor shall include pertinent Medicare claims information in its referral, if not previously provided to the RO. It also shall immediately refer a case to the RO if the MSP Contractor is named in any legal proceeding seeking to define or limit Medicare’s right to recovery. It does not make referrals simply because a lawsuit has been filed between the beneficiary and the liable third party. However, it monitors such lawsuits so that timely referrals can be made to the RO if CMS’s claim becomes an issue in the lawsuit. CMS may notify a State Insurance Commissioner, or other official having jurisdiction over a GHP or employer/ other plan sponsor, that evidence suggests that Federal law was violated. CMS may request that the GHP’s or employer/ other plan sponsor’s actions be investigated, and that it be ordered to comply with Federal law and to make the appropriate refund to Medicare. CMS may also advise the State Insurance Commissioner, or other responsible official, that the Medicare beneficiary is placed at risk by the GHP’s actions and that Medicare will not make future primary payments for items and services covered by the GHP for this individual. The RO advises these officials that Medicare may recover from any parties to whom it has made improper payments. CMS may also consider possible legal action against the GHP or employer/other plan sponsor and/or referral of the case to the Equal Employment Opportunity Commission (EEOC). The ROs may consult with Central Office (CO), the HHS Office of the General Counsel (HHS OGC), the EEOC, and other appropriate entities regarding referral determinations.