40. On August 16, 2019, Avmed and Plaintiff entered into an Assignment agreement (the “Assignment”). See Assignment attached as Exhibit B.  42. Each of the individual claims set forth herein has been assigned to Plaintiff. The claims are not subject to any carveouts, exclusions, or any other limitations in law or equity that would impair Plaintiff’s right to bring this cause of action.  43. The allegations set forth herein plainly demonstrate that Plaintiff’s assignor suffered damages as a direct result of Defendant’s individual failure to reimburse conditional payments as required under the MSP Law.  44. In addition, Section 1395y(a)(1)(A) of the Medicare statute states that, “no payment may be made under [the Medicare statute] for any expenses incurred for items or services which ... are not reasonable and necessary for the diagnosis or treatment of illness or injury.”  45. Because this section contains an express condition of payment – that is, “no payment may be made” – it explicitly links each Medicare payment to the requirement that the particular item or service be “reasonable and necessary.”  46. Once an MAO (or Medicare Payer) makes a payment for medical items and services on behalf of its enrollees, the payment is conclusive proof that the items and services were reasonable and necessary.  47. The items and services received by and paid on behalf of Plaintiff’s assignor’s Enrollees, including W.T. and W.M. below, were reasonable and necessary to treat the injuries suffered by each of the Enrollees.  49. On January 11, 2017, W.T. was enrolled in a Medicare Advantage plan issued and administered by Avmed, Inc. a Florida corporation d/b/a Avmed Health Plans and Avmed Medicare (“Avmed”). Avmed is a MAO.  50. On January 11, 2017, W.T. was injured in an accident. At the time of the accident, W.T.’s accident-related medical costs and expenses were also covered under a no-fault policy issued by Defendant. By virtue of its no-fault policy Defendant was contractually obligated to pay and provide primary coverage for W.T.’s accident-related medical expenses.  51. A list of the diagnosis codes and injuries assigned to W.T. in connection with W.T.’s accident-related treatment is attached hereto as Exhibt C.  52. The medical providers subsequently issued bills for payment of the accident-related medical expenses to W.T.’s MAO, Avmed.  53. As W.T.’s MAO, Avmed was fully responsible for all medical expenses incurred by W.T. Avmed paid $509.32 for W.T.’s accident-related medical expenses. The medical provider actually billed and charged Avmed $1,921.00 for W.T.’s accident-related medical expenses.  54. Defendant is liable to pay this amount because it was W.T.’s primary payer by virtue of a no-fault insurance policy which covered W.T. for the accident-related medical expenses detailed herein.  56. This reporting demonstrates that Defendant was aware of the accident and its responsibility to reimburse Avmed. A true and correct copy of Defendant’s report to CMS is attached hereto as Exhibit A.6 Despite Defendant reporting that it was a primary payer, and the corresponding admission that it should have paid for W.T.’s accident-related injuries, Defendant failed to do so, giving rise to a claim under the MSP Act.  57. Accordingly, Plaintiff is entitled to collect double damages against Defendant for its failure to reimburse Avmed’s conditional payment for W.T.’s accident-related expenses. The W.M. Claim Demonstrates Plaintiff’s Right to Recover for Defendant’s Failure to Meet its Reimbursement Obligations under the MSP Law  58. On December 3, 2016, W.M. was enrolled in a Medicare Advantage plan issued and administered by Avmed.  59. On December 3, 2016, W.M. was injured in an accident. At the time of the accident, W.M.’s accident-related medical costs and expenses were also covered under a no-fault policy issued by Defendant. By virtue of its no-fault policy Defendant was contractually obligated to pay and provide primary coverage for W.M.’s accident-related medical expenses.  61. The medical providers subsequently issued bills for payment of the accident-related medical expenses to W.M.’s MAO, Avmed.  62. As W.M.’s MAO, Avmed was fully responsible for all medical expenses incurred by W.M. Avmed paid $92.75 for W.M.’s accident-related medical expenses. The medical provider actually billed and charged Avmed $1,234.76 for W.M.’s accident-related medical expenses.  63. Defendant is liable to pay this amount because it was W.M.’s primary payer by virtue of a no-fault insurance policy which covered W.M. for the accident-related medical expenses detailed herein.  64. In fact, Defendant reported and admitted to CMS that it was the primary payer for W.M., including information regarding the accident, the name of the reporting entity, and the type of insurance policy involved.7  66. Accordingly, Plaintiff is entitled to collect double damages against Defendant for its failure to reimburse Avmed’s conditional payment for W.M.’s accident-related expenses. 67. This matter is brought as a class action pursuant to Federal Rule of Civil Procedure 23, on behalf of all Class Members or their assignees who paid for their beneficiaries’ accident- related medical expenses, when Defendant should have made those payments as primary payer and should have reimbursed the Class Members.  68. As discussed in this class action Complaint, Defendant has failed to provide primary payment and/or appropriately reimburse the Class Members for money they were statutorily required to pay under the MSP Law. This failure to reimburse applies to Plaintiff , as the rightful assignee of those organizations that assigned their recovery rights to Plaintiff, and to all Class Members. Class action law has long recognized that, when a company engages in conduct that has uniformly harmed a large number of claimants, class resolution is an effective tool to redress the harm. This case, thus, is well suited for class-wide resolution.  69. Class Members have been unlawfully burdened with paying for the medical costs of their beneficiaries when the law explicitly requires Defendant to make such payments. The Medicare Act and its subsequent amendments were constructed to ensure an efficient and cost- effective system of cooperation and communication between primary and secondary payers. Defendant’s failure to reimburse Plaintiff and Class Members runs afoul of the Medicare Act and has directly contributed to the ever-increasing costs of the Medicare system.  71. The Class is properly brought and should be maintained as a class action under Rule 23(b)(3) because a class action in this context is superior. Pursuant to Rule 23(b)(3), common issues of law and fact predominate over any questions affecting only individual members of the Class (“Damages Class”). Defendant, whether deliberately or not, failed to make required payments under the MSP Law and failed to reimburse Class Members and those organizations that assigned their recovery rights to Plaintiff , thus depriving Plaintiff , as assignee of the right to recovery, and Class Members of their statutory right to payment and reimbursement.  72. It is the custom and practice of CMS and primary plans to maintain records in a detailed electronic format. Based on these practices, Plaintiff maintains a reasonable methodology for generalized proof of Class-wide impact, using the MSP System. The MSP System captures, compiles, synthesizes and analyzes large amounts of data in order to identify claims for reimbursement of conditional payments. This case will not present manageability problems as compared to non-electronic data driven class actions. There is no need for a fact-specific individual analysis of intent or causation, and damages will be calculated based upon the total fee-for-service amounts associated with the payments made on behalf of Enrollees. Plaintiff is capable of using the MSP System to identify and quantify Class Members’ claims, as it has done for its own claims.  74. Administering the proposed Damages Class will be relatively simple. Defendant provided no-fault policies with claimants who are also Medicare beneficiaries. Once that data identifying these policies is compiled and organized, Plaintiff can determine which of the policy holders were Medicare beneficiaries during the applicable time. Then, using the database, Plaintiff and the Class Members can identify those payments made for medical treatment where the Defendant was (1) the primary payer and (2) for which reimbursement was not made. 78. Plaintiff incorporates by reference paragraphs 1 through 76 of this Complaint.  79. Plaintiff asserts a private cause of action pursuant to 42 U.S.C. § 1395y(b)(3)(A) on behalf of themselves and all similarly-situated parties.  80. The elements of a cause of action under 42 U.S.C. § 1395y(b)(3)(A) are: (1) the Defendant’s status as a primary plan; (2) the Defendant's failure to provide for primary payment or appropriate reimbursement; and (3) damages. Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229, 1239 (11th Cir. 2016).  81. Defendant’s no-fault policies are primary plans, which rendered the Defendant a primary payer for accident-related medical expenses.  82. As part of providing Medicare benefits to Medicare beneficiaries enrolled under the Medicare Advantage program, the Class Members and Plaintiff’s assignors paid for items and services which were also covered by no-fault policies issued by Defendant.  83. More specifically, Plaintiff’s and the Class Members’ Medicare beneficiaries were also covered by no-fault, PIP, or medical payments policies issued by the Defendant.  84. Because the Defendant is a primary payer, the Medicare payments for which Plaintiff seeks reimbursement were conditional payments under the MSP Law.  86. Plaintiff and the Class Members have suffered money damages as a direct result of Defendant’s failure to reimburse the accident-related medical expenses.  87. Defendant has derived substantial profits by placing the burden of financing medical treatments for their policy holders upon the shoulders of Plaintiff’s assignor and the Class members.  88. In this case, Defendant failed to administratively appeal the assignors’ rights to reimbursement within the administrative remedies period on a class wide basis. Defendant, therefore, is time-barred from challenging the propriety or amounts paid.  89. Plaintiff, for itself and on behalf of the Class Members, brings this claim pursuant to 42 U.S.C. § 1395y(b)(3)(A), to recover double damages from Defendant for its failure to make appropriate and timely reimbursement of conditional payments for the Enrollees’ accident-related medical expenses. 90. Plaintiff incorporates by reference paragraphs 1 through 76 of this Complaint.  92. Plaintiff complied with any conditions precedent to the institution of this action, to the extent applicable.  93. Defendant failed and/or refused to make complete payments of the Enrollees’ accident-related expenses as required by its contractual obligations.  94. Defendant failed to pay each enrollee’s covered losses, and Defendant had no reasonable proof to establish that it was not responsible for the payment.  95. Defendant’s failure to pay the medical services and/or items damaged Plaintiff and the Class Members as set forth herein. Plaintiff and the Class Members processed and paid accident-related medical expenses and are entitled to recover up to the statutory policy limits for each of the Enrollees’ medical expenses related to the subject accidents, pursuant to their agreements with CMS and the provider of services. Direct Right of Recovery Pursuant to 42 C.F.R. § 411.24(e) for Breach of Contract  Private Cause of Action Under 42 U.S.C. § 1395y(b)(3)(A) 