Set-Asides Without Safe Harbor

In May 2013, this blog reported that a New Jersey court had done what the Centers for Medicare & Medicaid Services (CMS) declined to do. In Duhamell v. Renal Care Group East, Inc., 431 N.J. Super. 93 (Law Div. 2012), the Superior Court in Atlantic County approved two self-administered Medicare set-asides after CMS refused to review them, citing limited resources. Thirteen years later, CMS still will not grant a safe harbor outside its own review process, but it now sees nearly every set-aside that gets created. For injured workers in New Jersey, that shift changes the calculus of every lump-sum settlement.

Single Payer’s Workers’ Compensation Gamble

For more than a decade, this blog has tracked what I have called “The Path to Federalization,” the steady, incremental expansion of federal authority over what was once an exclusively state-run workers’ compensation system. From the World Trade Center Health Program in 2010 to the Affordable Care Act’s Libby Care pilot, from Supreme Court validation of the individual mandate in 2012 to the Medicare Secondary Payer offset debate, each chapter has added a new stone to that path. California’s 2026 gubernatorial race is laying the boldest stone yet.

CMS Penalties Hit Workers' Compensation

Workers' Compensation - Medicare Secondary Payer Compliance

Medicare's Post-Acute Care Crisis

Post-acute care has emerged as a critical pressure point in workers' compensation claims, driven by Medicare policy changes and skyrocketing costs that directly impact claim settlements and future medical allocations.

Podcast: Chevron Falls: Workers' Compensation Survives

This podcast reviews the workers' compensation landscape one year after the US Supreme Court's Loper Bright decision, which struck down the Chevron defense.

Navigating Physician Payment Changes

The Centers for Medicare & Medicaid Services (CMS) has recently unveiled its proposed rule for the Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS). This proposal outlines significant changes that will shape how physicians are reimbursed for their services going forward, and stakeholders will need to understand the potential implications.

Medicare's Magic Number: $750 for Workers' Compensation 2025

The Centers for Medicare and Medicaid Services (CMS) has announced that it will maintain the current threshold of $750 for workers' compensation settlements in 2025. This threshold determines when settlements must be reported to Medicare and conditional payments must be repaid. Let's dive into what this means and how CMS made this decision.

Chevron's Fall: Medicare Set-Asides Face Legal Shake-Up

The recent U.S. Supreme Court decision in Loper Bright Enterprises v. Raimondo (2024), which overturned the Chevron doctrine established in Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., is likely to have significant impacts on how the Centers for Medicare & Medicaid Services (CMS) operates regarding the Medicare Secondary Payer (MSP) Act, including conditional payments and Medicare Set-Aside (MSA) agreements. 

CMS Expands Options for Defense Submissions for CRCP

Commercial Repayment Center Portal (CRCP) Defense Submission Frequently Asked Questions

Recently a change was made to the portal that allows CRCP users to associate defenses to the individual claims included in recovery demands. This more granular response to demands, where Group Health Plans (GHPs) specify the basis of defense submissions, allows for more efficient and accurate reviews of the submitted defenses. What follows are answers to frequently asked questions received by the Commercial Repayment Center (CRC) in regard to this change. Additional details on the functionality are available in Version 3.2 of the CRCP User Guide, which is available in the “Reference Materials” section of the CRCP.

CMS Health Care Workers Vaccination Deadline March 15, 2022

The Centers for Medicare and Medicaid Services (CMS) issued guidance that the full vaccination compliance deadline is March 15, 2022, for all health care workers subject to the Omnibus Health Care Staff Vaccination rule.

CMS Announces 2022 Workers' Compensation Recovery Threshold to Remain at $750.00

Computation of Annual Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers' Compensation Settlements, Judgments, Awards, or Other Payments for 2022 were announced this week.

CMS stopped from imposing vaccine mandate

The Centers for Medicare and Medicaid Services [CMS] has been halted from imposing a vaccine mandate on a wide range of healthcare facilities. A federal court in Missouri found in favor of a group of 11 Republican states when it issued an injunction against the proposed rule.

CMS Webinar on the PAID Act

To implement the  Provide Accurate Information Directly (PAID) Act*, enacted December. 11, 2020 the Centers for Medicare and Medicaid Services has scheduled a webinar. The program will stream on Wednesday, June 21, 2021.

Investigative Report Raises Issues

The tension between public pension systems and workers' compensation programs was highlighted in a recent investigative report by the NJ State Comptroller. The report raises additional critical issues common to other state and national collateral social insurance programs challenged by current fiscal limitations.

CMS Cannot Seek Reimbursement from Insurance Guarantee Fund

The US 9th Circuit Court of Appeals has ruled that The Centers for Medicare and Medicaid [CMS] cannot not seek reimbursement from from the California Insurance Guarantee Association for workers' compensation payments.

Trump Administration Proposes Elimination of the Reverse Offset

The Trump Administration in its proposed FY 2020 Budget has proposed elimination of the workers’ compensation reverse offset. The elimination will act as a cost saving measure and will level the playing field for all workers’ compensation system throughout the United States.

CMS has scheduled another webinar for Wed., Sept 19, 2018

Commercial Repayment Center Portal (CRCP) Overview Webinar Wednesday, September 19 th, 2018 CMS will be hosting a webinar to present an overview of the Commercial Repayment Center Portal (CRCP) functions.

Medical Fees: Does One Price Fit All?

The Federal government has proposed a simplified medical billing process that may impact workers' compensation billing practices going forward. Most workers' compensation fee medical fee schedules are linked either directly and indirectly the to Federal Medicare model and a proposed Rule published last week in the Federal Register proposes a single fee for all office visits.

NJ Mandates Reporting of Medicare Conditional Payments

The NJ Division of Workers’ Compensation has now mandated the reporting of pending workers’ compensation claims possibly eligible for reimbursement of conditional medical payments to the US Centers for Medicare and Medicare Services  (CMS) as a condition precedent to the settlement of a pending claim for benefits.  The directive was outlined in a memorandum issued by Russell Wojtenko, Jr., Director and Chief Judge of Compensation on April 18, 2018.

Just Published: 2018 Update - Gelman on Workers' Compensation Law

Jon Gelman’s newly revised and updated 2018 treatise on Workers’ Compensation Law is now available from by West Group of Egan, MN within the next few weeks. The treatise is the most complete work available on NJ Workers’ Compensation law and integrated with WESTLAW™, the "most preferred online legal research service.'"