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 What follows is a verbatim rendition of the facts, analysis, findings and conclusions found in the report.



“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

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

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

CMS Publishes Alert for Medical Providers Regarding Accepting Payment from Medicare Beneficiaries with a Medicare Set Aside

Posted by Rafael Gonzalez on Sep 26, 2017 4:00:00 PM

Slowly, but surely, the Centers for Medicare and Medicaid Services (CMS) is making sure medical providers are aware, informed, and prepared to deal with Medicare beneficiaries who must pay their future medical expenses related to a settlement, judgment, award, or other payment from a Medicare Set Aside (MSA). As I blogged about on March 10, 2017, in early 2017, CMS announced a set of codes for Medicare contractors to deny providers’ request for payment of a claim if there existed an open MSA.

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Topics: Liability, Medicare Law, 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