DaVita, Inc. v. Virginia Mason Memorial Hospital, No. 19-35692 (9th Cir. 2020)Annotate this Case
DaVita filed suit under the private cause of action under the Medicare Secondary Payer provisions (MSP), alleging that defendants reduced the payment amount for Patient 1's dialysis because of Medicare eligibility as soon as Patient 1 became eligible for Medicare, without waiting the mandatory thirty months. But the reduced payment amount remained greater than the Medicare rate, so Medicare never made any secondary payments. The district court dismissed the complaint, holding that the MSP's private cause of action is available only when Medicare has made a payment.
Reviewing de novo, the Ninth Circuit held that the district court erroneously dismissed the complaint on that ground. The panel explained that the statutory text, congressional purpose, and regulatory clues make clear that Congress did not intend payment by Medicare to be a prerequisite to bringing a private cause of action under the MSP. The private cause of action encompasses situations in which a primary plan impermissibly takes Medicare eligibility into account too soon, even if Medicare has not made any payments. Accordingly, the panel vacated in large part and remanded for further proceedings. The panel affirmed the district court's dismissal with respect to the 10-month period after Patient 1 dropped coverage under Virginia Mason's Plan.