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

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

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

Achieving MSP Compliance: Mitigating, Reducing, and Eliminating MSP Risks

Posted by Rafael Gonzalez on Nov 6, 2017 10:00:00 AM

Without a doubt, the most efficient model to achieve an exceptional Medicare program, which mitigates, reduces, and in some instances eliminates the risks previously discussed, is to build a comprehensive compliance process that relies on automated sequences and triggering events throughout the three steps of current Medicare Secondary Payer (MSP) compliance: Mandatory Insurer Reporting (MIR), Conditional Payment Resolution (CPR), and Medicare Set Aside Allocations, Approval, and Administration (MSA). What follows is part four 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 fourth part focuses on Flagship’s comprehensive MSP compliance program, which we believe to be the most efficient model in achieving 100% MSP compliance.

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Topics: Compliance

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

Social Security Number Removal Initiative (SSNRI) now known as “New Medicare Cards”

Posted by Gina Cox on Jul 28, 2017 8:00:00 AM

The Centers for Medicare & Medicaid Services (CMS) announced this week that the Social Security Number Removal Initiative (SSNRI) will now be known as “New Medicare cards.” Regardless of what the program is called, the bottom line is that the old Social Security Number based Health Insurance Claim Number (HICN) will be replaced by a new Medicare Beneficiary Identifier (MBI). This is not exactly new news as the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 required CMS to remove Social Security Numbers from all Medicare cards by April 2019 and CMS announced the upcoming transition earlier year.

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Topics: CMS, Compliance, Claims Processing

Florida Federal Court Orders Beneficiary to Reimburse Higher Conditional Payments, Despite Medicare’s Verbal Representation of Lower Amount Due

Posted by Rafael Gonzalez on Apr 6, 2017 8:00:00 AM

On March 23, 2017, the United States District Court for the Southern District of Florida published its opinion on Shapiro v. Secretary of Department of Health and Human Services, concluding that, even though Plaintiff and her attorney may have relied on Medicare’s verbal representation of $17,306.03 in conditional payments to settle the case, absent a waiver from CMS or its contractors in writing, the MSP Act requires Plaintiff to reimburse Medicare, and permits the Secretary of HHS to recover, the full $23,552.96 it paid in conditional payments from date of accident thru date of settlement. Since Plaintiff did not request a waiver for reimbursing all or part of the debt based on financial hardship, and failed to prove recovery is against equity and good conscience, court concludes plaintiff did not suffer a material detriment as she would still received 96% of settlement proceeds she agreed to.

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Topics: Compliance, Medicare Law, Conditional Payments

Florida Federal District Court Finds Med-Pay Policy Proves Primary Payer Responsibility and Allows MSP Private Cause of Action for Double Damages

Posted by Rafael Gonzalez on Mar 29, 2017 8:00:00 AM

On March 15, 2017, the United States District Court for the Southern District of Florida published its opinion on MSPA Claims I v. Century Surety Company, concluding that based on the USCA 11th Circuit opinions MSP Recovery, LLC v. Allstate Insurance Co., and Humana Medical Plan, Inc. v. Western Heritage Insurance Co., MSPA Claims I, an assignee of a Medicare Advantage Plan (MAP), has the right to recover medical expenses the MAP paid on behalf of one of its enrollees from Century Surety Company, the liability insurer that issued a commercial liability insurance policy with a Med-Pay clause. The court finds that MSPA Claims I has a private cause of action under the Medicare Secondary Payer Act (MSPA), as Century Surety is responsible for the payment of the medical expenses based on the existence of the Med-Pay policy and its denial in reimbursing same.

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Topics: Compliance