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

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

The 2017 Social Security Trustees Report: Old Age and Survivors Trust Fund Holds Steady, While Disability Trust Fund Sees Significant Improvement

Posted by Rafael Gonzalez on Jul 25, 2017 8:15:00 AM

On July 13, 2017, the Board of Trustees of the Federal Old Age, Survivors Insurance and Federal Disability Insurance Trust Funds published its 2017 Annual Report. “The Old-Age, Survivors, and Disability Insurance (OASDI) program makes monthly income available to insured workers and their families at retirement, death, or disability. The OASDI program consists of two parts. Retired workers, their families, and survivors of deceased workers receive monthly benefits under the Old-Age and Survivors Insurance (OASI) program. Disabled workers and their families receive monthly benefits under the Disability Insurance (DI) program.”

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Topics: Medicare Law

The 2017 Medicare Trustees Report: Hospital Trust Fund Remains in Short and Long Term Trouble, Supplemental Trust Fund is Adequately Financed

Posted by Rafael Gonzalez on Jul 24, 2017 11:22:30 AM

On July 13, 2017, the Boards of Trustees for the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds published its 2017 Annual Report. “The Medicare program has two separate trust funds, the Hospital Insurance Trust Fund (HI) and the Supplementary Medical Insurance Trust Fund (SMI). HI, otherwise known as Medicare Part A, helps pay for hospital, home health services following hospital stays, skilled nursing facility, and hospice care for the aged and disabled. SMI consists of Medicare Part B and Part D. Part B helps pay for physician, outpatient hospital, home health, and other services for the aged and disabled who have voluntarily enrolled.

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Topics: Medicare Law

Finally, a Re-Review Process for Work Comp Medicare Set Asides, But Still No Formal Appeals Rights for Claimants and Employer/Carriers

Posted by Rafael Gonzalez on Jul 18, 2017 3:31:11 PM

The Centers for Medicare & Medicaid Services (CMS) has put together a mechanism to receive and evaluate future medical and future prescription drug costs for inclusion in Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs). The Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) is a web-based application that allows attorneys, beneficiaries, claimants, insurance carriers, representative payees, and WCMSA vendors to create a work-in-progress case, submit WCMSA cases, perform case lookups, append documentation to a case, receive alerts relating to case activity, and now submit a re-review request.

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Topics: CMS, Medicare Law

19 Million Americans and Growing: 33% of the 57 Million Medicare Beneficiaries are Enrolled in a Medicare Advantage Plan in 2017

Posted by Rafael Gonzalez on Jun 16, 2017 4:39:33 PM

On June 6, 2017, The Henry J. Kaiser Family Foundation published Medicare Advantage 2017 Spotlight: Enrollment Market Update. Written by Gretchen Jacobson and Tricia Newman from the Kaiser Family Foundation, Anthony Damico, an independent consultant, and Marsha Gold, a Senior Fellow Emeritus with Mathematica Policy Research and an independent consultant, the study highlights the fact that “Medicare Advantage plans have played an increasingly larger role in the Medicare program as the share of Medicare beneficiaries enrolled in Medicare Advantage has steadily climbed over the past decade.”  The trend in enrollment growth is continuing in 2017, and has occurred despite reductions in payments to plans enacted by the Affordable Care Act of 2010 (ACA).  The Data Spotlight “reviews national and state-level Medicare Advantage enrollment trends as of March 2017 and examines variations in enrollment by plan type and firm. It also analyzes the most recent data on premiums, out-of-pocket limits, and quality ratings.” The study can be found here.

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Topics: Beneficiaries