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

Florida Federal District Court Prohibits State Medicaid Agency from Seeking Reimbursement of Past Medicaid Payments from Future Medical Recovery

Posted by Rafael Gonzalez on May 3, 2017 2:30:00 PM

On April 18, 2017, the United States District Court for the Northern District of Florida, Tallahassee Division, published its opinion on Gianinna Gallardo v. Elizabeth Dudek, Secretary of Florida Agency for Health Care Administration, concluding that Florida’s Medicaid reimbursement statute is preempted by federal Medicaid law. The court indicates that by allowing the Agency for Health Care Administration (AHCA)—Florida’s agency charged with administering Medicaid—to satisfy its lien from settlement funds allocated to both past and future medical expenses, Florida has run afoul of the federal Medicaid statute. The court also determines that the same is true for Florida’s Medicaid reimbursement statutory formula. Specifically, Florida’s reimbursement statute—which only allows the Medicaid recipient to rebut that formula-based allocation by presenting clear and convincing evidence that it is inaccurate—amounts to a quasi-irrebuttable presumption and thus conflicts with and is preempted by federal law.

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Topics: Medicare Law

California’s WCAB Remands Case to Look at Agreement Between Parties on Whether Claimant Allowed to Self Administer His MSA Account Funds

Posted by Rafael Gonzalez on Apr 19, 2017 9:00:00 AM

On March 21, 2017, the California Workers Compensation Appeals Board published its opinion on Fernando Muniz Villalpando v. Doherty Brothers; Martin Dusters; State Compensation Insurance Fund, concluding that in deciding whether to allow a claimant to go from having his MSA professionally administered to self-administering his own MSA account, the trial judge must examine the terms of the parties’ agreement, and whether it included any provision for a change of administration in the event the hired vendor ceased to operate or withdraw from providing the contracted services over the life of the agreement. The Appeals Board makes it clear that the trial judge should be provided the opportunity to consider the nature of the agreement between the employer/carrier, claimant, and vendor, and whether there is any provision for a change of administration, and if none, the nature of claimant’s contractual remedies.

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Topics: Medicare Law

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

Case Law Update: California Federal District Court Finds Medicare Is Not Entitled to Reimbursement for Unrelated Care in Bundled Codes

Posted by Rafael Gonzalez on Feb 2, 2017 2:47:48 PM

On January 5, 2017, the United States District Court for the Central District of California published its decision on California Insurance Guarantee Association v. Burwell, finding that the Secretary of Health and Human Services’ interpretation of the Medicare Secondary Payer Act and its relevant regulations are contrary to law and not entitled to deference. The Court concludes that Medicare is not entitled to reimbursement for medical items and services that, although imbedded in bundled codes containing related and unrelated care, are not related to the claim at hand and are therefore not payable under the workers compensation policy administered by the California Insurance Guarantee Association.

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Topics: Medicare Law

Montana Supreme Court Concludes Only Way for Insurer to Satisfy Obligation to Reimburse US is to Pay the US Directly

Posted by Rafael Gonzalez on Dec 13, 2016 2:44:05 PM

On November 9, 2016, the Supreme Court of the State of Montana published its opinion on WEST, as Guardian Ad Litem for Peter Lee v. United Services Automobile Association (USAA) and USAA Casualty Insurance Company, concluding that USAA did have a reasonable basis to condition its settlement payment on waiver of the TRICARE lien from the United States. The court makes it clear that the  “only way” for USAA to satisfy its statutory obligation to reimburse TRICARE is to pay the United States, not to pay Lee. If USAA had not honored the lien, the United States could have gone after USAA to enforce its right to reimbursement. Accordingly, the court holds that USAA’s “grounds for conditioning payment were reasonable under existing law.” The court therefore reverses the District Court’s grant of summary judgment in favor of West and orders it to enter summary judgment in favor of USAA.

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Topics: Medicare Law

A Year Later, How is the New CRC Process Going?

Posted by Rafael Gonzalez on Nov 28, 2016 10:59:20 AM

Recently, we celebrated a year since 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). 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 has 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, as the assumption is that the AP’s responsibility is not in dispute.

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Topics: Compliance, CRC, Medicare Law