Medicare Secondary Payer Compliance Blog

MSP Blog: 2019


The Lyrica Saga Continues

1/17/2019

By Lori Dickson, MSN, RN, MSCC, CLCP, CNLCP, Director of Clinical Operations

Updated WCMSA Reference Guide Provides Surprising Insight into Medicare Set Aside Policies

1/9/2019

By Marty Cassavoy, VP of Medicare Secondary Payer Compliance Services and Lori Dickson, Director of Clinical Operations

CMS released WCMSA Reference Guide version 2.9 which provides no major substantive policy announcement but it does clarify some key issues that we follow closely. The updates concern two primary areas: policy and technical updates and injury and treatment-specific clarification. These are the critical insights workers’ compensation claims practitioners need to know: 

MSP Blog: 2018


Medicare Introduces Self-Reporting

12/19/2018

By Marty Cassavoy, VP of Medicare Secondary Payer Compliance Services

The holiday season is always a busy one for the Federal Medicare Secondary  Earlier today Medicare hosted a brief webinar outlining two enhancements to the Medicare Secondary Payer Recovery Portal (MSPRP).  If you blinked, you may have missed it, but the representative reading the presentation packed a ton of information into that 30 minute period.  Here are the key items that you need to know:

Section 111 Civil Money Penalties: Issue Rises from the Dead, Placed in CMS-Induced Coma

12/12/2018

Marty Cassavoy, VP of Mediare Secondary Payer Services

December is often quite a busy month in the Medicare Secondary Payer space, and this year is no different.  On the heels of last week’s announcement regarding possible regulations regarding the treatment of post-settlement medical, CMS unveiled its intention to file a notice of proposed rulemaking regarding civil money penalties in section 111 reporting, –albeit not until the third quarter of 2019. As with last week’s announcement, the document is light on details.  Here’s the text of the announcement:

CMS Announces Intention to Make Future Announcement Regarding LMSAs

12/7/2018

By Marty Cassavoy, VP of Medicare Secondary Payer Services

Lyrica® Patent Extended

11/29/2018

By Dr. Nahla D. Rizkallah, MSCC Senior Clinical Pharmacist

Lyrica has been a hot-button topic for claims involving Medicare Set Asides.  Medicare’s Workers’ Compensation Review Contractor (WCRC) has been far more aggressive in incorporating Lyrica into Medicare Set Asides (MSAs) where submitters had been previously more successful in making “off-label” arguments to include MSAs.  Underlying those changes has been the fact that Pfizer’s patent on Lyrica was expected to expire on December 30, 2018.

New MSP Recovery Portal Functionality and Recovery Thresholds Still $750

11/20/2018

By Marty Cassavoy, Vice President of Medicare Secondary Payer Compliance

During this holiday week, it might be easy to miss a CMS update on portal enhancements and 2019 thresholds.

ExamWorks Clinical Solutions’ Chronicle: Who is Medicare eligble?

11/12/2018

ExamWorks Clinical Solutions welcomes you to our LinkedIn Chronicle. In these brief articles, we will cover the ins and outs of all things related to Medicare Secondary Payer, MMSEA Section 111 Reporting, and Case Management. Our articles will uncover basic concepts and then move through the many nuances involved, helping you navigate the oftentimes complicated regulations and processes. In addition, our subject matter experts will be addressing and sharing FAQs and lessons learned.

Stay At Work/Transitional Return-To-Work Programs

10/29/2018

By Lori Dickson, MSN, RN, MSCC, CLCP, CNLCP, Director of Clinical Operations

Stay At Work/Transitional Return To Work Programs

Constitutional Challenge to Treasury Offsets in Conditional Payments Falls Flat: Massachusetts Man’s Moon Shot Lands with a Thud

10/16/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Compliance

A Federal Magistrate in a Massachusetts Federal Court dismissed a Navy veteran’s attempt to have the reliance upon Treasury offsets to collect Medicare conditional payments declared unconstitutional.  The decision to dismiss the case, predictably relies upon the exhaustion of administrative remedies.  It is the unique facts of the case that highlight the pitfalls of dealing with an increasingly aggressive Treasury offset process. The case is cited as Mouradian v. United States Government, 2018 U.S. Dist. LEXIS 161863 (D. Mass.).

Ever-Changing AWP

10/11/2018

Dr. Nahla Rizkallah, Senior Clinical Pharmacist

Allocation and pricing of medications within the Workers Compensation Medicare Set-Aside Arrangement (WCMSA) Part D is done so in accordance with the WCMSA Reference Guide as published by Center for Medicare and Medicaid Services (CMS). As a result, WCMSA medications are priced using the lowest average wholesale price (AWP) by the recognized proprietary source: Truven Health Analytics’ Red Book database. Further, generic medications are priced at the lowest non-repackaged AWP.  

Three Updates from Medicare as We Enter Q4

10/9/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Compliance

October 1st marks the start of a new quarter and the issuance of three updates covering all aspects of Medicare Secondary Payer compliance.  Two updates involve minor changes to Medicare’s User Guides, and the other incorporates additional functionality for the conditional payment portal.  Here’s a short summary of the updates, beginning with the most useful:

ExamWorks Clinical Solutions’ Chronicle

9/24/2018

ExamWorks Clinical Solutions welcomes you to our Chronicle. In these brief articles, we will cover the ins and outs of all things related to Medicare Secondary Payer, MMSEA Section 111 Reporting, and Case Management. Our articles will uncover basic concepts and then move through the many nuances involved, helping you navigate the oftentimes complicated regulations and processes. In addition, our subject matter experts will be addressing and sharing FAQs and lessons learned.

Case Management: Did You Know

9/18/2018

By Becky Bro, M.Ed, CRC, National Director Vocational and Disability Services

Return-To-Work Stats and What They Mean

Reviewing Amended Review: Top Three Guidelines for Success

8/20/2018

By Patricia Kent, Medicare Secondary Payer Compliance Counsel

CMS’ new “Amended Review” process has been in place for a year. Amended Review allows parties to – in certain select circumstances – obtain a second shot at the Medicare Set-Aside approval.  This new process is separate from the “standard” Medicare Set-Aside reconsideration process.  Let’s take a look. 

Welcome to the ExamWorks Clinical Solutions’ Chronicle

8/15/2018

ExamWorks Clinical Solutions welcomes you to our Chronicle. In these brief articles, we will cover the ins and outs of all things related to Medicare Secondary Payer, MMSEA Section 111 Reporting, and Case Management. Our articles will uncover basic concepts and then move through the many nuances involved, helping you navigate the oftentimes complicated regulations and processes. In addition, our subject matter experts will be addressing and sharing FAQs and lessons learned.

Companion Medicare Set Aside Bill Introduced in House of Representatives

8/2/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Compliance

A new Medicare Set Aside bill was introduced in the House of Representatives on Thursday July 26th.  The bill, which appears to be a companion to a bill previously introduced in the Senate on June 18th, is sponsored by Rep. Dave Reichert (R-WA) and co-sponsored by Rep. Mike Thompson (D-CA).  The text on H.R. 6619 is not yet available however we would anticipate that it is more or less identical to S. 3079.

CMS to Hold Webinar on Conditional Payment Portal

7/31/2018

By Lou Porrazzo, Director of Conditional Payment Research 

Earlier this month CMS introduced new elements to the Medicare Secondary Payer Recovery Portal.  Last night CMS announced that it will hold a webinar on Thursday August 16th to walk through the new features. An overview of the webinar, including call-in instructions, can be found here.

As we previously outlined, the recently introduced changes offer improved functionality and greater efficiency for all stakeholders. In some cases parties will be able to download an electronic conditional payment letter. The portal also features a new section that provides real-time information regarding correspondence, including disputes and appeals. 

Arizona Industrial Commission Issues New Guidance on Settlements

7/24/2018

By Marty Cassavoy, Vice President of Medicare Secondary Payer Compliance 

Patricia Kent RN and JD, Medicare Secondary Payer Compliance Counsel

The Industrial Commission of Arizona released updated advisory guidance for full and final settlements.  The document provides a list of suggested Best Practices for Practitioners when resolving claims full and final in the State of Arizona.  

Progress in Conditional Payments

7/15/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Compliance

Lou Porrazzo, Director of Conditional Payment Research

With more than half of 2018 on the books, it’s a good time to check in on Medicare’s conditional payment process. There are a number of changes to Medicare’s conditional payment program that had an impact on day-to-day claims handling – mostly for the better.  Here’s a recap of some of the key changes that we have seen this year.

Another Average Wholesale Price Change

7/1/2018

By Dr. Nahla D. Rizkallah, Senior Clinical Pharmacist

Another average wholesale price (AWP) has changed. As part of best practices, ExamWorks Clinical Solutions continually monitors the Center for Medicare and Medicaid Services (CMS’s) recognized proprietary source, Red Book, for real-time changes to AWP for medications used to treat the injured worker. It is noted that pricing of morphine sulfate products have been reduced considerably:

Updated Medicare Set Aside Bill Introduced in Senate

6/25/2018

By Marty Cassavoy, Vice President Medicare Secondary Compliance

A new bill S. 3079 to revamp the Medicare Set Aside (MSA) process has been introduced in the U.S. Senate.  The bill sponsored by Sen. Rob Portman (R-OH) and co-sponsored by Sen. Bill Nelson (D-FL). Is known as the “Medicare Secondary Payer and Workers’ Compensation Settlement Agreements Act of 2018,” represents a stripped down version of previous Medicare Set Aside bills.  

Ever-Changing Average Wholesale Pricing: Gabapentin

5/4/2018

Ever-Changing AWP

Trouble in Medicare Advantage paradise?  Court victories reveal cracks in the foundation.

3/19/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Compliance Services

When it comes to the Medicare Secondary Payer (MSP) statute, Medicare Advantage organizations (MAOs) have had more than their share of litigation success.  It may be of cold comfort, but  some of the recent victories have laid bare the contradictions inherent in the MAOs’ strategy.  The most recent case reveals a split with another federal district court that bears watching.  Let’s catch up on these cases to reset the table on Medicare Advantage.

Medicare Advantage Update: New Case in Connecticut

3/17/2018

Medicare Advantage Update: New Case in Connecticut

Meet Capitol Bridge

3/7/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Services

On Wednesday March 7th the Centers for Medicare & Medicaid Services (CMS) introduced the new Workers’ Compensation Review Contractor (WCRC).  Effective Monday March 19th, Capitol Bridge, LLC will take over the WCRC responsibilities currently held by Provider Resources, Inc.  The forty minute conference call provided an overview of Capitol Bridge’s background and how the contractual transition will work.  Here’s a recap of the webinar:

Meet the New Workers’ Compensation Review Contractor

3/2/2018

The Centers for Medicare & Medicaid (CMS) is hosting a webinar to introduce Capitol Bridge and conduct a question and answer session. CMS announced Capitol Bridge will be installed as the Workers’ Compensation Review Contractor effective March 19, 2018. The contract was awarded last year.

Are section 111 fines and penalties around the corner?

2/26/2018

By Scott Huber, Senior Vice President of Technology

In the ten years following the introduction of mandatory insurer reporting, we have yet to see any evidence of enforcement in the form of the imposition of dreaded civil money penalties.  Could changes be on the horizon?  Here’s a primer on the civil money penalties provisions of mandatory insurer reporting.

What’s Old is New Again: Medicaid Secondary Payer

2/12/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Services

Medicaid conditional payments appear to be dead.  After five years of kicking the can down the road, Congress finally acted to resolve uncertainty surrounding when states will be able to expand their recovery rights.  The recently signed Bipartisan Budget Act of 2018 permanently repeals a 2013 amendment to Federal law that allowed states to recover from non-medical portions of personal injury settlements.  By including a permanent repeal of the provision, Congress breathes new life into two older Supreme Court cases whose holdings had been significantly curtailed by the 2013 amendment.  State Medicaid programs will now be limited once again to proportional recovery from third-party settlements where a Medicaid program pays for medical treatment.

Meet the New Commercial Repayment Center Contractor

1/17/2018

By Marty Cassavoy, Vice President Medicare Secondary Payer Services

The Centers for Medicare & Medicaid Services (CMS) and Performant held a joint introductory webinar today, a little more than three months after Performant was announced as the “new” Commercial Repayment Center (CRC) Contractor.  During the one-hour conference call, Performant representatives and CMS laid out the transition plan and fielded questions that they selected from an online queue.  Here are key points all insurers, self-insureds and TPAs need to know:

ExamWorks Clinical Solutions Introduces New Management Options for Medicare Set Aside Post-Settlement Administration Services in Partnership with Ametros Financial

1/10/2018

By Christie Britt, Senior Vice President of Operations

ExamWorks Clinical Solutions (ExamWorks) announced today new Medicare Set Aside (MSA) post-settlement administration (PSA) features for professional administration and self-administration through its partnership with Ametros Financial. As a result of the alliance, Ametros’ CareGuard™ and Amethyst™ healthcards will be available to ExamWorks Clinical Solutions clients who elect to use Ametros’ post-settlement account services to simplify ongoing administration.

WCMSA User Guide Six-Month Follow Up: Spinal Cord Stimulator Pricing and State-Specific Statutes

1/4/2018

By Annie M. Davidson Esq., MSP Compliance Counsel 

Earlier this year the Centers for Medicare and Medicaid Services (CMS) released a significant update to its Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide. As with any significant update, experience over time provides insight as to how the Workers’ Compensation Review Contractor (WCRC) interprets the new guidance. Below is an update on what we see.

MSP Blog: 2017


The Latest Gift from CMS: Updated Section 111 User Guide

12/29/2017

Like clockwork, count on the Centers for Medicare & Medicaid Services (CMS) to issue new guidance either around the Fourth of July or Christmas.  This year is no different, as CMS released an updated NGHP Section 111 Reporting User Guide earlier this week.  The changes are not earth-shattering, but are more substantive than the last several updates.

CMS Statement Tips a Tepid Toe on Opioids in Medicare Set Asides

12/20/2017

By Marty Cassavoy VP Medicare Secondary Payer Services

CMS responds with a short statement on opioids, but makes no commitment to review process or policy changes, leaving submissions to a trial and error process. Last month we reported on a study from the California Workers’ Compensation Institute (CWCI) highlighting the link between the Centers’ for Medicare & Medicaid Services (CMS) approval process and life-long opioids.  The study, which followed approximately 8,000 CMS-approved Medicare Set Asides (MSAs) involving California workers’ compensation claimants, made the case that CMS policy in this area was antiquated and in need of a re-boot. 

2018 MSP Reporting and Recovery Thresholds Remain $750

11/27/2017

Annie M. Davidson MSP Compliance Counsel

CMS announced it will maintain the existing $750 reporting and recovery thresholds for physical trauma-based liability settlements and for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals. Settlements of $750 or less are exempt from conditional payment recovery as well as Section 111 reporting, notwithstanding ORM reporting obligations.

Medicare's Workers' Comp Policies Intersect the Opioid Crisis

11/7/2017

By Marty Cassavoy VP Medicare Secondary Payer Services

Last week the California Workers’ Compensation Institute (CWCI) published a fascinating study on the intersection between the opioid crisis and Medicare Set Aside (MSA) review and approval. The CWCI data clarifies what many in the Medicare Secondary Payer compliance community have long known; the Medicare Set Aside review program inflates future medical care costs in a way that bears little relation to the actual needs of individual patients. Where opioids are concerned, the differences can be quite remarkable.

Performant Is the Next CRC Contractor

10/5/2017

By Marty Cassavoy VP Medicare Secondary Payer Compliance

CMS awarded the next Commercial Repayment Center (CRC) contract to Performant Financial Corporation today. The news breaks on the two year anniversary of the launch of the CRC’s ongoing responsibility for medicals (ORM) recovery program. Barring a bid protest the incumbent contractor, CGI Federal, will be phased out over the coming months.

ExamWorks Clinical Solutions Names Jeffrey D. Gurtcheff President

10/2/2017

ExamWorks Clinical Solutions, LLC, the industry leader in Medicare Secondary Payer compliance solutions and case management services, announced today that Jeffrey D. Gurtcheff has been appointed President. Mr. Gurtcheff, a 30 year industry visionary, has demonstrated exceptional leadership and innovation in the employ of industry leading third-party administrators, and insurers with a holistic understanding of workers' compensation, property and casualty, liability, and disability claim management

New Medicare Card Unveiled

9/14/2017

By Marty Cassavoy VP Medicare Secondary Payer Compliance

On September 14th the Centers for Medicare & Medicaid Services (CMS) released the design of the new Medicare cards that it will begin sending to beneficiaries in April 2018.  The new cards, which we have previously written about here, here, and here, are designed to substantially reduce the use of Medicare cards in fraud and identity theft. 

ExamWorks Clinical Solutions Hires Martin R. Cassavoy as Vice President of MSP Compliance

9/12/2017

ExamWorks Clinical Solutions (“ECS” or the “Company”), the industry leader in Medicare Secondary Payer (MSP) compliance and case management services and solutions, announced today that Martin R. Cassavoy joined the team as Vice President of Medicare Secondary Payer Compliance. 

Capitol Bridge Awarded WCRC Contract

9/8/2017

On September 1, 2017, the Centers for Medicare and Medicaid Services (CMS) announced the award of the WCRC contract to Capitol Bridge, LLC (Capitol Bridge).  CMS began the contract renewal process back in December 2016 searching for an entity to “independently price the future Medicare-covered medical services costs related to WC injury, illness and disease, and to price the future Medicare covered prescription drug expenses.” Capitol Bridge, designated as a minority owned business, was awarded the new $60.7 million contract until August 31, 2018. The award to Capitol Bridge replaces the current contractor Provider Resources, Inc. which has held the WCRC contract since 2012.

Expanded Re-Review Process for MSAs Among Changes Announced in the WCMSA Portal User Guide Update

7/11/2017

On July 10, 2017, the Centers for Medicare and Medicaid Services (CMS) released updates to its user guide for the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP). You may find a copy of the updated version (version 5.1) here. Below is a summary of the changes, and information on how these changes may impact your claims.

Movement in the MSP Compliance Realm? Update on Liability and No-Fault Medicare Set-Asides

7/9/2017

In a previous Industry News Bulletin, we noted that CMS seemed to be taking affirmative first steps on Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs). Since the time of that writing, we have seen a few revisions to the change request notice provided to Medicare Administrative Contractors (MACs). The most recent revision to the change notice was released on June 8, 2017. This change request issued by the Centers for Medicare and Medicaid Services (CMS) to its contractors continues to outline a timeline for back-end technical changes to modify Medicare’s Common Working File (CWF) to address LMSAs and NFMSAs.

New Law Governing Closeouts of Future Medicals in Arizona Workers’ Compensation Settlement Agreements

6/16/2017

On May 8, 2017, Arizona Governor Doug Doucey signed an amendment impacting the workers’ compensation law governing settlements that close out future medical treatment on admitted claims. The legislature voted to repeal Section 23-941.01[i] and replace it with an amended version[ii]. The old version allowed release of future supportive medical maintenance benefits, but disallowed closure of active treatment in admitted claims. The new amendment is effective as of October 31, 2017 and allows the closure of all future medical benefits by way of a settlement agreement if specific criteria are met.

As the Commercial Repayment Center Turns; Must Practices in Handling Conditional Payments

3/16/2017

By Christie Britt, Senior Vice President of Operations, ExamWorks Clinical Solutions

The Commercial Repayment Center (CRC) has been on the job for the last eighteen months. It’s time for a progress report on this contractor, which has reset the timeline for conditional payment investigations.

California to Roll Out Formulary July 1st, 2017: The Good and the Bad of Drug Formularies

3/10/2017

By Devon Mahaney, PharmD Manager of Pharmacy Services for ExamWorks Clinical Solutions

At the most recent Department of Workers’ Compensation (DWC) Educational Conference held on February 23rd, George Parisotto, Acting Administrative Director Division of Workers’ Compensation, updated attendees on the status of the development of the California formulary. The formulary is set to go live on July 1st, 2017, and will be based on medical treatment standards set by the American College of Occupational and Environmental Medicine (ACOEM) in an effort to remain consistent with the Medical Treatment Utilization Schedule (MTUS) guidelines.

SPARC Act Re-Introduced in Congress: Adjusters and Attorneys on Notice

3/2/2017

By Annie M. Davidson MSP Compliance Counsel for ExamWorks Clinical Solutions

On February 17, 2017, Congressman Tim Murphy (R-PA) re-introduced the Secondary Payer Advancement, Rationalization, and Clarification Act, or SPARC Act. The bill is styled as HR 1122 and is co-sponsored by Rep. Ron Kind (D-WI). The aim of the SPARC Act is to clarify the Medicare Secondary Payer (MSP) program when Medicare Part D is involved. For historical precedent, click here

CMS Takes First Steps on LMSAs

2/27/2017

By Annie M. Davidson MSP Compliance Counsel for ExamWorks Clinical Solutions

Last week CMS released a change request to modify Medicare’s Common Working File (CWF) to address a new Liability Medicare Set-Aside (LMSA) policy. The announcement establishes a timeline for back-end technical changes and provides clues to Medicare’s new policy. A copy of the notice can be found here.

MSP Blog: 2016


ExamWorks Clinical Solutions and Chronovo Announce iMSA; Structured Settlement Solution Improves Settlements for All Stakeholders

11/28/2016

ExamWorks Clinical Solutions (ECS) announced today an exclusive agreement with structured settlement broker, Chronovo, to deliver an innovative solution to the Medicare Set-Aside (MSA) space for workers’ compensation and liability settlements, called the iMSA.

CMS Reduces Liability Recovery Threshold to $750 for 2017

11/17/2016

After announcing two months ago that CMS was maintaining the recovery threshold for physical trauma-based liability settlements at $1,000 for 2016, CMS has now issued an Alert that as of 1/1/2017 the liability recovery threshold will be reduced to $750.  CMS further announced in this 11/15/2016 Alert that in 2017 it will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals. 

CMS Improves Functionality and Access to MSPRP

11/9/2016

The Centers for Medicare and Medicaid Services (CMS) released an updated version of the Medicare Secondary Payer Recovery Portal (MSPRP) User Guide (Version 3.5) which documents improved functionality and access on the MSPRP including portal use for matters pending with the Commercial Repayment Center (CRC). Given the delays in obtaining documentation from the CRC, the expansion of the portal to cover claims with the CRC is an improvement in CMS’s Medicare conditional payment processes.

CMS Announces Rollback of Rule Change Impacting Legal Zero MSAs

11/1/2016

ExamWorks Clinical Solutions recently issued an Industry News Bulletin concerning an abrupt rule change to a long-standing CMS policy regarding approval of Legal Zero MSAs (see article here).  CMS provided no notification of the rule change prior to the rule’s implementation by the Workers’ Compensation Review Contractor (WCRC).  Accordingly, following our confirmation of the rule change with the WCRC, we immediately placed all Legal Zero MSA matters on hold and voiced ours concerns regarding this unannounced rule change to the CMS Central Office in Baltimore. 

CMS Implements Rule Change to Long-Standing Legal Zero MSA Policy;  New Document Submission Required; Recommended Procedural Options

10/27/2016

ExamWorks Clinical Solutions (ECS) was advised by the Centers for Medicare and Medicaid Services (CMS) that a Legal Zero MSA (“no liability” or “Zero allocation” MSA) based solely upon the employer or carrier’s complete denial of the claim will not be approved. Such a denial is typically evidenced by a claim payment history documenting no payments for medical treatment and indemnity and a letter from the adjuster or defense attorney confirming such a denial.

CMS Implements $750 Settlement Threshold for WC Conditional Payment Recovery; Maintains $1,000 Threshold in Liability

9/29/2016

A September 26, 2016 CMS Alert (Alert) announced the implementation of a $750 conditional payment recovery threshold for no-fault and workers’ compensation settlements.  CMS also announced it is maintaining the $1,000 conditional payment recovery threshold for liability settlements, a threshold which has been in place since January 1, 2014.

Court Holds MAP Assignees May Maintain Claims for Reimbursement Against No-Fault and PIP Plans

9/27/2016

The 11th Circuit U.S. Court of Appeals, which includes Florida, Alabama and Georgia under its jurisdiction, has found that Medicare Advantage Plans (MAPs) may assign their rights of recovery under the MSP Act to another party.  The consequence of the ruling is that MAPs or their assignees may assert a claim for reimbursement against no-fault and personal injury protection (PIP) plans for payments made by the MAPs deemed to be related to a claimed injury, including a claim for double damages.  

Medicare Advantage Plans Prevail Again Before a Federal Appeals Court

8/23/2016

Double Damages and MAPs – What You Need To Know: On August 8, 2016, the U.S. Eleventh Circuit Court of Appeals upheld an order from the lower federal district court granting summary judgment in favor of Humana[i] regarding Western Heritage Insurance Company’s (Western’s) obligation to reimburse Humana for Medicare benefits paid on behalf of its Medicare Advantage plan enrollee, Mary Reale, and its claim for double damages pursuant to the Medicare Secondary Payer Act (MSP).   In affirming the district court’s order, the Eleventh Circuit specifically agreed with and adopted the Third Circuit Court of Appeals’ reasoning and holding in In re Avandia[ii] a prior successful decision for Medicare Advantage plans

Removal of SSN from Medicare Cards to Impact MSP Compliance

6/21/2016

A law passed in 2015 eliminated Social Security Numbers (SSNs) from Medicare ID cards, also known as Health Insurance Claim Numbers (HICNs).  Congress and the President required use of a MBI to minimize the risk of identity theft for Medicare beneficiaries and to reduce opportunities for fraud within the program.

CMS Considers New Effort to Expand MSA Review Process to Liability

6/10/2016

The Centers for Medicare and Medicare Services (CMS) is considering expanding the voluntary Workers’ Compensation MSA review process to include review of liability and no-fault insurance MSA amounts.   The June 9, 2016 notice states as follows:

CMS Publishes Alert for Additional Excluded ICD Codes for Section 111 Reporting

5/25/2016

On Monday, May 23, 2016, the Centers for Medicare & Medicaid Services (CMS) published a Technical Alert regarding new excluded diagnosis codes.  The alert can be found here.

CMS Final Rule for Process and Timeline to Obtain Final MSP Conditional Payment Amounts via Web Portal

5/23/2016

On May 17, 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule entitled “Medicare Program: Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal”.  While the rule will be effective June 16, the process defined by the rule was initiated by CMS in December 2015. See prior ECS article "CMS Initiates Process Allowing for Obtaining Final Conditional Payment Amount Pre-Settlement".  The final rule provides the official guidance on the how and when this Pre-Settlement Final Conditional Payment process may be utilized by the settling parties.

CMS Releases Bulletin Explaining Delay in Issuance of CPLs, CPNs and Demand Letters

2/11/2016

CMS published a Bulletin on February 9, 2016 addressing issues encountered in implementation of Conditional Payment recovery actions against insurers. See bulletin here. According to CMS, the CRC has issued more than 33,000 Conditional Payment Letters (CPLs) and Conditional Payment Notices (CPNs) since the transition. CMS advised that it is aware that many insurers and WC entities are awaiting CPLs, CPNs, or demand letters. CMS has engaged with the CRC to improve responsiveness to requests for conditional payment information and the handling of correspondence.

California Independent Medical Review Determinations More Widely Accepted by CMS

1/26/2016

One of the most significant recent developments in limiting unnecessary medical care costs in California workers’ compensation came with the July 1, 2013, implementation of the Independent Medical Review (IMR) process. The IMR statute allows workers’ compensation claimants to appeal Utilization Review (UR) denials of medical care with the resulting IMR determination binding upon the parties. Initially, the Centers for Medicare and Medicaid Services (CMS) refused to recognize IMR determinations as providing a basis for limiting medical care in a Medicare Set Aside (MSA), thus maintaining their normal practice of largely relying upon the opinions and recommendations of the treating physician to allocate future medical care. More recently, ExamWorks Clinical Solutions (ECS) has identified favorable trends in CMS recognition of IMRs in MSA submissions.

Takemoto False Claims Act Case Dismissed

1/23/2016

A suit under the Federal False Claims Act against more than 50 insurance stakeholders filed in the U.S. District Court for the Western District of New York has been dismissed. In 2011, Dr. Kent Takemoto filed this action to recover damages and civil penalties on behalf of the United States of America arising from insurers and self-insured companies for their alleged failure to repay known government obligations in violation of the Federal False Claims Act, 31 U.S.C. §§ 3729 et seq. Specifically, the suit requested damages for failure to comply with the obligations imposed by the Medicare Secondary Payer ("MSP") statute, 42 U.S.C. § 1395y(b)(2).

ECS Web Presentation: Guide to the new CMS Pre-Settlement Final Conditional Payment Amount Process

1/10/2016

In late December CMS launched the long-awaited process for obtaining the final conditional payment amount prior to settlement. The process is very rigid in its requirements making very easy for one to run afoul of its strict timelines. ExamWorks Clinical Solutions is pleased then to offer this one-hour web presentation which will provide attendees a how to guide for utilizing this new process to obtain the final conditional payment amount pre-settlement. The presentation will also update attendees with the latest on actions by CMS's Commercial Repayment Center (CRC) to recover for conditional payments made during periods of ongoing responsibility for medical by the employer or insurer.

MSP Blog: 2015


CMS Initiates Process Allowing for Obtaining Final Conditional Payment Amount Pre-Settlement

12/31/2015

On Monday, December 21, 2015 the Centers for Medicare and Medicaid Services  (CMS) published an Alert entitled: Modification of the Medicare Secondary Payer  Recovery Portal (MSPRP) for Inclusion of Final Conditional Payment (CP) Process  Functionality. CMS has completed the implementation of an electronic  method that allows claimants or their authorized representatives to obtain the  final conditional payment amount within three days of final settlement as  opposed to initiating lien investigation and resolution in anticipation of settlement  without a concrete time frame. The process through the MSPRP is very rigid in its  requirements which may limit its usefulness to parties settling workers’  compensation and liability cases.

CMS Webinar Expounds on Commercial Repayment Center Procedures

9/2/2015

On Tuesday, August 23rd, 2015 CMS held a webinar further explaining the new  policies and procedures for conditional payment recovery through the  Commercial Repayment Center (CRC) and the Benefits Coordination and Recovery  Center (BCRC). On July 1, 2015, CMS first announced that it would be transitioning  a portion of the NGHP recovery workload from the Benefits Coordination &  Recovery Center (BCRC) to the CRC. CMS explained that the transition was part of  a continuing effort to improve the conditional payment recovery and its accuracy  in Medicare Secondary Payer (MSP) situations.

Legal Update on Medicare Advantage Plan Recovery Rights

8/23/2015

The latter half of 2014 and, thus far, 2015 have been busy times for Medicare  Advantage Plans (MAPs) seeking clarification of their rights under the Medicare  Secondary Payer (MSP) Act. MAPs, or “Part C providers” argue that the MSP Act  and federal regulations outlining the right of Medicare Advantage Organizations  are broad enough to allow providers of Medicare benefits to enjoy the same  federal preemptive rights that Medicare Parts A and B routinely resort to when  seeking recovery against settling parties. They argue that they are entitled to  maintain a private cause of action against insurers who fail to reimburse them for  care provided to a Medicare beneficiary and to recover double damages from  those entities.

CMS Publishes Updated NGHP User Guide to Include Recent Alerts and the NGHP Town Hall Teleconference

7/13/2015

On Monday, July 13th, 2015 the Centers for Medicare and Medicaid Services (CMS) published version 4.7 of the MMSEA Section 111 Non-Group Health Program (NGHP) User Guide, found here.

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