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.
Other Vendors Only Check Traditional Medicare
Unlike all other Medicare and Medicaid Secondary Payer compliance vendors out there today assisting auto, liability, no-fault, and work comp insurers, self-insureds, and third party administrators, which only check Medicare A and B through the Medicare Secondary Payer Recovery Portal (MSPRP), at Flagship Services Group, we not only check with Medicare Parts A and B to ascertain whether traditional Medicare has made any payments related to the claim at hand, we also check with Medicare Parts C and D to determine whether any payments related to the claim were made by the beneficiary's Advantage Plan or Prescription Plan. And we also check with the state of jurisdiction Medicaid agency to learn whether the state Medicaid agency or any of its authorized Managed Care Organizations made any payments associated with the claimed injuries.
Other Vendors Only Provide Screen Shot of Portal
And unlike most other vendors in the Medicare and Medicaid Secondary Payer compliance space today, which simply provide the auto, liability, no-fault, and work comp primary responsible payer a copy of the MSPRP screen shot with recommendations to pay the amount determined owed by CMS, at Flagship, we provide our insurer, self-insured, and TPA clients with documentation from the Commercial Repayment Center (CRC) if ongoing responsibility for medical (ORM) was accepted and from the Benefits Coordination Recovery Center (BCRC) if total payment obligation to claimant (TPOC) has been reached. We also automatically provide our clients with recommendations for disputing any unrelated payments or policy exhaustion issues.
Other Vendors Do Not Check with MAPs or PDPs
And unlike any of our competitors in the Medicare and Medicaid Secondary Payer compliance space today, which do not provide their primary payer clients with any documentation and recommendations regarding Advantage Plan or Prescription Plan payments, at Flagship, we provide our insurer, self-insured, and TPA clients with documentation of such payments from the MAP or PDP. We also automatically provide our clients with recommendations for disputing any unrelated payments or policy exhaustion issues.
Other Vendors Do Not Check with Medicaid
And unlike a single one of our competitors in the Medicare and Medicaid Secondary Payer compliance space today, which do not provide primary payers with any documentation and recommendations regarding state Medicaid agency or managed care entity payments, at Flagship, we provide our insurer, self-insured, and TPA clients with documentation of such payments from the state Medicaid agency or its MCO. We also automatically provide our clients with recommendations for disputing any unrelated payments or policy exhaustion issues.
Flagship’s Conditional Payments Resolution Process
Our conditional payments dispute resolution process is unlike any other in the industry. Flagship uses its own internal medical and legal experts to review each payment made by traditional Medicare, MAP, PDP, state Medicaid, or MCO. We use a proprietary 60 step process to challenge, redetermine, and reconsider invalid payments. As a result, in our last 15,000 claims, our clients have enjoyed a 67% reduction in the amount they have ultimately reimbursed Medicare and Medicaid, saving them over $25 million.
A Recent Example
We recently worked on a 2016 date of injury California claim involving both a liability and no-fault policy. The claimant was a 90 year old Medicare beneficiary, severely injured in an auto accident, with cervical vertebra fractures and left radius fractures. As a result, the adjuster offered policy limits of $1 million on the liability policy and $250,000 on the no-fault policy, thereby totaling $1.25 million.
The adjuster's offer was accepted by the claimant and her counsel. Knowing that the claimant was a Medicare beneficiary, the adjuster asked a well known national vendor to check with Medicare for conditional payments. The vendor checked the MSPRP, which showed $0 as current conditional payments amount, and provided a copy of the screen shot showing same to the adjuster.
Suspecting "there was more to this," the adjuster asked Flagship to assist in determining whether any conditional payments were due. Immediately, we made contact with claimant counsel and learned claimant was not receiving Medicaid, had never purchased PDP coverage, but was enrolled in a MAP. After obtaining authorization, Flagship requested documentation from the MAP and soon thereafter learned the MAP had paid over $570,000 in conditional payments related to the claim.
Since a settlement offer had been made and accepted, the case had in fact settled. As a result, the adjuster asked Flagship for release language recommendations to be provided to insurer counsel for inclusion in the final general release. As we do on every case, Flagship provided insurer counsel with suggested release language that made certain and clear that the obligation to reimburse the MAP's conditional payments belonged to claimant and her counsel out of the settlement proceeds.
We are Conditional Payments Experts
Had the case settled without specifically addressing the MAP's reimbursement right, and the MAP later sought such reimbursement from the insurer directly, the insurer may have had to pay same, in addition to having already exhausted its $1.25 million policy payout, or litigate the issue with potential double damages as a recovery for the MAP. Either way, not a great position to be in, or a positive outcome to be had.
This is what we do for our clients day in and day out. This is what Flagship provides its clients in every single case. We offer the most consistent, robust, and detailed conditional payments resolution process in the country. Unlike vendors focusing on mandatory reporting, or set aside allocations, our focus and expertise is on conditional payments compliance and resolution. Flagship identifies, investigates, analyzes, disputes, appeals, resolves, and closes out such claims not just with traditional Medicare Parts A and B, but also with Medicare Parts C Medicare Advantage Plans and D Prescription Drug Plans, as well as Medicaid.
About Medicare Conditional Payments
42 CFR Section 411.21 indicates that Medicare conditional payments are payments made by Medicare for medical treatment where a primary payer (insurer or self-insurer) has or may have an obligation to make such payment. Primary payers must reimburse Medicare for conditional payments it has made. 42 USC Section 1395y indicates that primary payers include group health providers, workers’ compensation, liability and no-fault insurers and self-insured entities, as well as physicians, attorneys, hospitals, or clinics that receive payment from a primary payer must make reimbursement.
42 USC Section 1395y also indicates responsibility as a primary payer arises even if liability for the medical expense is contested. Such a responsibility can be demonstrated by entry of a judgment or by payment conditioned on a release or waiver of payment, even if liability is denied. 42 CFR Section 411.24 indicates Medicare has a direct right of action against all primary payers responsible for making payment. And, Medicare has a direct right of action against any person or entity that received a primary payment, including the Medicare beneficiary, medical provider, physician, attorney, state agency or private insurer.
About Medicare Advantage and Prescription Drug Plans Liens
42 CFR Section 422.108(f) provides MAPs with the same rights of recovery that the Secretary of HHS has under the MSP regulations in subparts B through D of part 411 of 42 CFR. Additionally, the same MSP regulations at 42 CFR Section 422.108 are extended to PDPs at 42 CFR Section 423.462. Therefore, PDPs have the same MSP recovery rights as MAPs, which have the same recovery rights as HHS. This includes, as recent federal appellate and district court decisions have indicated, the ability to pursue double damages through MSP private cause of action pursuant to 42 USC Section 1395y(b)(3) should the primary payer deny the MAP or PDP reimbursement of any due conditional payments.
About Medicaid Liens
42 USC Section 1396a mandates that all reasonable measures to ascertain legal liability for Medicaid payments and reimbursement of same be taken. The state or agency administering a Medicaid plan must take all reasonable measures to ascertain the legal liability of third parties to pay for care and services paid by Medicaid. Federal law also provides that in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual, the state or local agency must seek reimbursement for such assistance to the extent of such legal liability. 42 U.S.C. Section 1396a(a)(25).
The 2013 Strengthening Medicaid Third Party Liability Act, effective October 1, 2017, allows state Medicaid agencies or the insurers/managed care organizations contracted with to provide such benefits to seek reimbursement from any responsible third party of all payments made from the entirety of settlement, judgment, award funds, not just a portion thereof.
About Flagship Services Group
Flagship Services Group is the premier Medicare compliance services provider to the property & casualty insurance industry. Our focus and expertise has been the Medicare and Medicaid compliance needs of P&C self-insureds, insurance companies, and third party administrators. We specialize in P&C mandatory reporting, conditional payment resolution, and set aside allocations. Whether auto, liability, no-fault, or work comp claims, we have assembled the expertise, experience and resources to deliver unparalleled MSP compliance and cost savings results to the P&C industry. To find out more about Flagship, our folks, and our customized solutions, please visit us at www.flagshipservicesgroup.com. To speak with us about any of our P&C MSP compliance products and services, you may also contact us at 888.444.4125 or firstname.lastname@example.org.
About Rafael Gonzalez
Rafael Gonzalez, Esq. is President of Flagship Services Group. 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 blogs on these topics at Medicare Compliance for P&C Insurers at www.flagshipservicesgroup.com/blog. He is very active on LinkedIn, Twitter, Instagram, and Facebook. He can be reached at email@example.com or 813.967.7598.