Rafael Gonzalez

Rafael Gonzalez, Esq. has been a part of the insurance, medical, and disability industry since 1983. He has served as a thought leader on all aspects of liability, workers compensation, social security, Medicare, and Medicaid compliance since 1990. He speaks and writes on mandatory insurer reporting, conditional payment resolution, set aside allocations, CMS approval, and MSA and SNT professional administration, as well as the interplay and effect of these processes and systems and the Affordable Care Act throughout the country. Rafael can be reached at rgonzalez@flagshipsgi.com or 813.967.7598.

Recent Posts

Progressive Insurance Company Settles Medicare and Medicaid Secondary Payer False Claims Act for $2.4 Million

Posted by Rafael Gonzalez on Nov 22, 2017 9:12:10 AM

Auto, liability, no-fault, and work comp primary payers- if you didn’t take Medicare and Medicaid secondary payer issues seriously before, here are over 2 million reasons why you should.

On November 14, 2017, the United States of America, the State of New Jersey, Progressive Garden State Insurance Company, Progressive Casualty Insurance Company, and Relator Elizabeth Negron entered into a settlement agreement for $2,392,700 on a False Claims Act matter in which certain Progressive automobile insurance policies caused health care providers to submit medical claims to Medicare and Medicaid in violation of secondary payer laws.

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Topics: medicare, medicaid

Mandatory Reporting Compliance Risks for Auto, Liability, No-Fault, and Work Comp Primary Payers

Posted by Rafael Gonzalez on Nov 17, 2017 10:00:00 AM

With Medicare still in financial short and long term trouble, the US Department of Health and Human Services (HHS), and its Center for Medicare and Medicaid Services (CMS), have become increasingly more aggressive about making sure Medicare is the secondary payer pre and post settlement in auto, liability, no-fault, and workers compensation claims. As a result, insurers, self insureds, and third party administrators responsible for payment of auto, liability, no-fault, and work comp claims must be aware of and understand their responsibilities under the Medicare Secondary Payer Act (MSP), and be prepared for the multiple risks associated with MSP compliance. What follows is part one of a four-part analysis of risks associated with each of the MSP compliance components: Mandatory Insurer Reporting (MIR), Conditional Payment Resolution (CPR), and Medicare Set Asides (MSA). This first of a four part series focuses on MIR compliance risks for auto, liability, no-fault, and work comp primary payers.

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Topics: Compliance

Florida Federal District Court Finds MAPs Must Abide by Same Laws and Regulations Imposed on Medicare When Seeking Reimbursement

Posted by Rafael Gonzalez on Nov 15, 2017 9:37:34 AM

On September 20, 2017, the United States District Court for the Southern District of Florida published its opinion on MSPA Claim I, LLC., v. National Fire Insurance Company of Hartford, finding that since it is undisputed that on June 4, 2014, at the time of the settlement in this case, the threshold amount referenced in paragraph (9) of the Medicare Secondary Payer Act (MSP) was set at $2,000, and that National Fire's settlement was for $1,500, the threshold to bring an MSP private cause of action is not met. The Court therefore concludes that Plaintiff does not state a cognizable claim under the MSP. Having found the threshold amount is not met, the Court did not reach the standing issue as to whether the Plaintiff had a valid assignment at the time it filed suit.

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Topics: CMS, Compliance, Medicare Law

CMS Publishes Alert for Medical Providers Regarding Accepting Payment from Medicare Beneficiaries with a Medicare Set Aside

Posted by Rafael Gonzalez on Sep 26, 2017 4:00:00 PM

Slowly, but surely, the Centers for Medicare and Medicaid Services (CMS) is making sure medical providers are aware, informed, and prepared to deal with Medicare beneficiaries who must pay their future medical expenses related to a settlement, judgment, award, or other payment from a Medicare Set Aside (MSA). As I blogged about on March 10, 2017, in early 2017, CMS announced a set of codes for Medicare contractors to deny providers’ request for payment of a claim if there existed an open MSA. https://www.flagshipservicesgroup.com/blog/yet-another-clue-that-cms-is-getting-ready-for-liability-and-no-fault-msas

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Topics: Liability, Medicare Law, Conditional Payments

Flagship Services Group: The Conditional Payments Resolution Experts

Posted by Rafael Gonzalez on Sep 20, 2017 8:30:00 AM

As we have continued to inform on this blog, at multiple conference presentations throughout the country, and at training sessions for current and potential clients over the last several years, conditional payments resolution isn't just about traditional Medicare any more. Today, conditional payments resolution is about identifying, investigating, analyzing, disputing, appealing, resolving, and closing such claims not just with Medicare Parts A (hospital) and B (physician) coverage, but also with Medicare Parts C (Medicare Advantage Plans) and D (Prescription Drug Plans), as well as Medicaid.

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Topics: Conditional Payments

Humana Advantage Plan Goes After Florida Plaintiff Lawyer for Failing to Reimburse Conditional Payments Related to Settled Claim

Posted by Rafael Gonzalez on Sep 14, 2017 2:00:00 PM

Medicare Secondary Payer (MSP) compliance has become an integral part of claims handling for both the injured plaintiff and his/her counsel, as well as the corporate defendant, its insurer, and its counsel. Litigants today must pay close attention and stay informed about plaintiff’s entitlement to Medicare, and whether Medicare makes any conditional payments related to the pending or settled claim. In addition, litigants today must know whether the plaintiff is enrolled in a Medicare Advantage Plan (MAP) or Prescription Drug Plan (PDP), and whether such plans make any conditional payments related to the pending or settled claim. Not knowing this will create havoc on your claim, your settlement, your practice, and your business.

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Topics: Compliance, CRC

Commercial Repayment Center Returned $88.35 Million to Medicare Trust Fund in FY 2016,  $125.05 Million in FY 2015, and  $50.6 Million in FY 2014

Posted by Rafael Gonzalez on Sep 1, 2017 10:00:00 AM

As Required by Section 1893(h) of the Social Security Act, the United States Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Medicare Secondary Payer (MSP) Commercial Repayment Center (CRC) published its third annual report to Congress for FY 2016 in August 2017. Based on the Group Health Plan (GHP) and Non-Group Health Plan (NGHP) recovery work of the CRC, for FY 2016 (October 1, 2015 through September 30, 2016), CMS returned $88.35 million dollars to the Medicare Trust Funds.

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Topics: CRC

Resolution of Conditional Payments Continue to Create Havoc on No-Fault Claims

Posted by Rafael Gonzalez on Aug 20, 2017 8:00:00 AM

Medicare conditional payments are serious business. They continue to challenge claims professionals throughout the country. And if not dealt with timely and appropriately, can create havoc on parties’ attempt to settle a claim, or future reimbursement responsibility.

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Topics: Conditional Payments, medicare

Leaving Reimbursement of Medicare Conditional Payments to Plaintiff May End Up Costing You

Posted by Rafael Gonzalez on Aug 16, 2017 1:00:00 PM

We all mean well. Everyone handling claims tries to do the right thing. But sometimes, things just don’t go as planned and end up taking significantly longer than expected and costing way more than agreed.

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Topics: Conditional Payments

A Complete Comparative Analysis of the Changes in the New Workers Compensation Medicare Set-Aside Arrangement Reference Guide

Posted by Rafael Gonzalez on Aug 4, 2017 4:17:19 PM

On July 31, 2017, CMS published Version 2.6 of the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide. The latest version of the Guide includes the following changes:

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Topics: medicare compliance, MSA, Medicare Law