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

NCCI Publishes 2018 Update on Medicare Set Asides and Workers Compensation

Posted by Rafael Gonzalez on Feb 12, 2018 10:22:14 AM

 

Rafael Gonzalez, Esq. President, Flagship Services Group

On February 8, 2018, the National Council on Compensation Insurance (NCCI) published its MEDICARE SET-ASIDES AND WORKERS COMPENSATION— 2018 UPDATE (study), written by Nedžad Arnautović. The study can be found at https://www.ncci.com/Articles/Documents/II_MSA-WC-Study.pdf What follows is a verbatim rendition of the facts, analysis, findings and conclusions found in the report.

 

INTRODUCTION

“In September 2014, NCCI published a study on Medicare Set-Asides (MSAs) in workers compensation. Using the sample of MSAs submitted to the Centers for Medicare & Medicaid Services (CMS) between September 2009 and November 2013 and completed between January 2010 and November 2013, the study examined several aspects related to Medicare Set Asides (MSAs), such as the distribution of amounts of MSAs and total settlements that include MSAs, claimants’ age distribution, the duration of time from submission to CMS approval, and the relation between submitted and CMS-approved MSA amounts. This paper provides an update and expansion of the previous MSA study using the larger data sample as well as additional experience from 2014 and 2015.”

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Topics: Compliance, Medicare Law

Here We Go Again, as New Medicare Contractor Takes Over Reimbursement of Conditional Payments When ORM Accepted

Posted by Rafael Gonzalez on Feb 1, 2018 10:06:51 AM

Rafael Gonzalez, Esq., President, Flagship Services Group

 

After 35 years of seeking reimbursement of conditional payments post settlement, judgment, award, or payment of a case, in 2015, the Centers for Medicare & Medicaid Services (CMS) transitioned a portion of the Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). As a result, on October 5, 2015, the CRC assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity, referred to as Applicable Plans (AP), as the identified debtor. Since then, CMS, through a contract with CGI, had been pursuing recovery directly from APs as the identified debtor when an applicable plan reports that it has ongoing responsibility for medicals (ORM) or otherwise notifies CMS of its primary payment responsibility.

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Topics: MSA, Medicare Law, Conditional Payments

MAP Assignees Settle MSP Class Action Against Ocean Harbor for $5 Million

Posted by Rafael Gonzalez on Jan 26, 2018 3:52:43 PM

 Close up of a lot of law reports in library.jpgOn January 12, 2018, in the Circuit Court of the 11th Judicial Circuit in and for Miami Dade County, Florida, MSPA Claims 1 filed its motion for approval of a class action settlement against Ocean Harbor Casualty Insurance. The settlement agreement is intended by the parties to fully, finally, and forever resolve, discharge, and settle all claims. The motion indicates that the settlement agreement provides a fair, flexible, speedy, cost-effective, and assured monetary settlement to the class members. Thus, the settlement agreement provides considerable benefit to the class members while avoiding costly litigation of difficult and contentious issues. The parties also indicate that the settlement agreement is a compromise, and shall not be construed as, or deemed to be evidence of admission or concession of liability or wrongdoing on the part of Ocean Harbor with respect to any claim of any fault or liability or wrongdoing or damage whatsoever.

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Topics: Medicare Law

On Behalf of Our Flagship Family, Wishing You a Wonderful Holiday Season

Posted by Rafael Gonzalez on Dec 30, 2017 1:21:42 PM

On behalf of everyone associated with Flagship, I wanted to take this opportunity to thank you, all of our friends, colleagues, and especially our customers, for your trust and confidence in Flagship. It truly means the world to us. To know that after all these years, despite all of the statutory amendments, the compliance challenges, and the regulatory changes, you still count on us for updates, information, training, guidance, and advice on all of your Medicare and Medicaid risk management issues is so very significant for each of us at Flagship.

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New Mexico Federal District Court Finds CMS’ Failure to Clarify if MSAs are Required in Liability Settlements Proving Burdensome in Settlement Process

Posted by Rafael Gonzalez on Dec 22, 2017 1:00:00 PM

On November 28, 2017, the United States District Court for the District of New Mexico published its opinion in Silva v. Burwell, concluding that the uncertainty created by CMS's repeated failure to clarify its position on requiring MSAs in personal injury settlements generally and in specific cases is proving burdensome to the settlement process. The Court further finds this case is not ripe for review because no federal law mandates CMS to decide whether Plaintiff is required to create a MSA. The Court reiterates that just because CMS has not responded to Plaintiff's requests to clarify whether an MSA is required in personal injury claims is not reason enough for this Court to step in and determine the propriety of its actions. There may be a day when CMS requires the creation of MSA's in personal injury cases, but that day has not arrived.

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Topics: CMS

Illinois Federal District Court Finds Surviving Spouse and Adult Children Must Reimburse Medicare $105,000 from Med Mal $250,000 Settlement

Posted by Rafael Gonzalez on Dec 20, 2017 10:00:00 AM

On November 26, 2017, the United States District Court for the Northern District of Illinois published its opinion on Paraskevas v. Price, concluding that Medicare did not abuse its discretion in finding that the state court settlement order was not on the merits and was therefore not binding on CMS when seeking reimbursement of conditional payments. The Court finds the settlement compensated Plaintiff not only for the wrongful death action, but also the estate’s survivor claims in connection with the medical malpractice claim. Medicare’s decision is affirmed, and the Secretary's final decision that Plaintiff owes $105,000 plus interest in reimbursement of conditional payments made stands.

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Topics: Medicare Law

Set Aside Allocation Compliance Risks for Auto, Liability, No-Fault, and Work Comp Primary Payers

Posted by Rafael Gonzalez on Nov 29, 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 three 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 third part focuses on MSA compliance risks for auto, liability, no-fault, and work comp primary payers.

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Topics: Compliance

Conditional Payment Compliance Risks for Auto, Liability, No-Fault, and Work Comp Primary Payers

Posted by Rafael Gonzalez on Nov 27, 2017 9:00:00 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 two 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 second part focuses on CPR compliance risks for auto, liability, no-fault, and work comp primary payers.

 

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Topics: Compliance, Liability, Conditional Payments

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