Workers' Compensation: CMS

Showing posts with label CMS. Show all posts

Friday, September 30, 2016

CMS 2016 Recovery Thresholds for Workers’ Compensation Settlements, Judgments, Awards or Other Payments

2016 Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments

As required by section 1862(b) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) has reviewed the costs related to collecting Medicare’s conditional payments and compared this to recovery amounts.

CMS Publishes Final Rule for MSP Conditional Payments Via Web Portal

This final rule, effective June 16, 2016, specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act).

And they didn't see it coming........

Rafael Gonzalez authored a very helpful, and spot on, post today that summarizes the new approach of The Centers for Medicare and Medicaid Services (CMS) to recoup benefits under Medicare Secondary Payer law (42 U.S.C. § 1395y(b)) (MSP) before a final determination is made in the underlying workers' compensation claim.

Rafael Gonzalez

With multiple reporting trigger points CMS is new able to capture data quickly and with the implementation of the expedited US Treasury debt collection procedures, the Digital Accountability and Transparency Act (DATA Act). the process will now ignore the sluggish/delayed workers' compensation program/adjudication.

CMS has now operationalized a new procedure, "As part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) will be transitioning a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its CommercialRepayment Center (CRC)."

Ironically, this process cuts through the red tape and cottage industry's interests of the State programs and moves the claims to the goal of Federalization of the entire system based also on a uniformity of processing, coding and determinations at the Federal administrative level. See also, D. Torrey, The Federalization Standards Issue, A Short History Before and After NFIB v. Sebelius (2012), ABA, 2013. "These views speak loudly to the expectation of educated observers that state-based workers’ compensation will endure and that federalization is unlikely."

Additionally, the cottage industries (lawyers, insurance carriers & employers, ie. MARC) who lobbied for The Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2011, never saw the forest from the trees as they tried to stake out their territory.

Perhaps, the very next step may be an effort to follow the liability program models, wherein pre-disposition, alternate resolution, is possible early in the process, ie. the mass tort specialized programs for resolution.

Of course, workers' compensation (WC) insurers and employers would then need to really expedite WC claims. But then, wasn't that the intent of the now antiquated 1911 system anyway?

Click below to read the post on LinkedIn:
New Process for Primary Payers Resolving Medicare Conditional Payments Begins Today

Thursday, July 9, 2015

CMS Announces Changes to Physician Fee Schedules: End of Life Care Discussion Payments Proposed

Under a new proposal announced by the Centers for Medicare and Medicaid Services, physicians will be paid to discuss "end of life care" with patients.

Today, CMS released the first proposed update to the physician payment schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal includes a number of provisions focused on person-centered care, and continues the Administration’s commitment to transform the Medicare program to a system based on quality and healthy outcomes.

“CMS is building on the important work of Congress to shift the Medicare program toward a system that rewards physicians for providing high quality care,” said Andy Slavitt, Administrator of CMS. “Thanks to the recent landmark Medicare and children’s health insurance program legislation, CMS and Congress are working together to achieve a better Medicare payment system for physicians and the American people.”

In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the Department to move the Medicare program to a health care system focused on the delivery of quality care and value.

The proposed rule includes updates to payment policies, proposals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Reporting System, which measures the quality performance of physicians participating in Medicare, and updates to the Physician Value-Based Payment Modifier, which ties a portion of physician payments to performance on measures of quality and cost. CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries.

The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.

The release of the rule triggers a 60-day comment period, during which time CMS welcomes the input of stakeholders and the public. A final rule will be published this fall. For a fact sheet on the proposed rule, Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule for Calendar Year 2016, please see here. For further information, please see the rule on display here.

Monday, June 1, 2015

GAO calls for better Medicare fee setting data and more transparency

Many state workers' compensation medical fee schedules are based upon Medicare rates. A new study from US Government Accounting Office reports that the underlying rate making scheme is biased and the GAO recommends increased transparency of the process.

The American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) has a process in place to regularly review Medicare physicians' services' work relative values (which reflect the time and intensity needed to perform a service). Its recommendations to the Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare, though, may not be accurate due to process and data-related weaknesses.

First, the RUC's process for developing relative value recommendations relies on the input of physicians who may have potential conflicts of interest with respect to the outcomes of CMS's process. While the RUC has taken steps to mitigate the impact of physicians' potential conflicts of interest, a member of the RUC told GAO that specialty societies' work relative value recommendations may still be inflated.

RUC staff indicated that the RUC may recommend a work relative value to CMS that is less than the specialty societies' median survey result if the value seems accurate based on the RUC members' clinical expertise or by comparing the value to those of related services.

Second, GAO found weaknesses with the RUC's survey data, including that some of the RUC's survey data had low response rates, low total number of responses, and large ranges in responses, all of which may undermine the accuracy of the RUC's recommendations. For example, while GAO found that the median number of responses to surveys for payment year 2015 was 52, the median response rate was only 2.2 percent, and 23 of the 231 surveys had under 30 respondents.

CMS's process for establishing relative values embodies several elements that cast doubt on whether it can ensure accurate Medicare payment rates and a transparent process.

First, although CMS officials stated that CMS complies with the statutory requirement to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews.

Second, CMS's process is not fully transparent because the agency does not publish the potentially misvalued services identified by the RUC in its rulemaking or otherwise, and thus stakeholders are unaware that these services will be reviewed and payment rates for these services may change.

Third, CMS provides some information about its process in its rulemaking, but does not document the methods used to review specific RUC recommendations. For example, CMS does not document what resources were considered during its review of the RUC's recommendations for specific services.

Finally, the evidence suggests—and CMS officials acknowledge—that the agency relies heavily on RUC recommendations when establishing relative values. For example, GAO found that, in the majority of cases, CMS accepts the RUC's recommendations and participation by other stakeholders is limited. Given the process and data-related weaknesses associated with the RUC's recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.

CMS has begun to research ways to develop an approach for validating RUC recommendations, but does not yet have a specific plan for doing so. In addition, CMS does not yet have a plan for how it will use funds Congress appropriated for the collection and use of data on physicians' services or address the other data challenges GAO identified.

Why GAO Did This Study
Payments for Medicare physicians' services totaled about $70 billion in 2013. CMS sets payment rates for about 7,000 physicians' services primarily on the basis of the relative values assigned to each service. Relative values largely reflect estimates of the physician work and practice expenses needed to provide one service relative to other services.

The Protecting Access to Medicare Act of 2014 included a provision for GAO to study the RUC's process for developing relative value recommendations for CMS. GAO evaluated (1) the RUC's process for recommending relative values for CMS to consider when setting Medicare payment rates; and (2) CMS's process for establishing relative values, including how it uses RUC recommendations. GAO reviewed RUC and CMS documents and applicable statutes and internal control standards, analyzed RUC and CMS data for payment years 2011 through 2015, and interviewed RUC staff and CMS officials.

What GAO Recommends
CMS should better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. CMS should also develop a plan for using funds appropriated for the collection and use of information on physicians' services in the determination of relative values. HHS agreed with two of GAO's recommendations, but disagreed with using rulemaking to inform the public of RUC-identified services. GAO clarified that the recommendation is not limited to rulemaking.

Click here to read the full report.
Better Data and Greater Transparency Could Improve Accuracy
GAO-15-434: Published: May 21, 2015. Publicly Released: May 21, 2015.

Thursday, May 28, 2015

In the name of privacy...

After the massive US IRS data breach announcement this week, CMS has posted that it is establishing a more secure system for access to Medicare Secondary Payer Information. This is pretty consistent with President Obama's announcement to take Social Security Numbers off of Medicare Cards.

The real issue is that while workers' compensation records are supposedly confidential in State systems, the Federal government has consistently neglected to insure that privacy whether be: medical records under HIPPA; by integration of state's motor vehicle or workers' compensation records utilizing Social Security Numbers, or by Medicare Secondary Payer Act electronic data systems.

Additionally, the Federal government will probably be mandating the reporting workers' compensation payment information, in Federal Income Returns shortly. The batting record of the IRS this week on privacy has been dismal.

Time will only tell whether workers' compensation data can actually be shielded from intruders.

CMS announced today:

"As part of the Strengthening Medicare and Repaying Taxpayers (SMART) Act, the Centers for Medicare & Medicaid Services (CMS) will be implementing optional MFA services on the MSPRP. MFA is the use of two or more different authentication factors to verify the identity of an end user. Verified users will have access to view unmasked claim data on the Portal.

"Non debtors will still need to have a Verified Proof of Representation or Consent to Release authorization to perform actions on cases. Please note that MFA and the associated identity proofing process will be optional to portal users. Portal users may continue to use the portal without going through the MFA process but will not have the benefit of viewing un-masked data.

"MFA is scheduled to be available beginning on July 13, 2015. Updated user guides and training materials will be available on CMS.gov and within the portal upon implementation.

Friday, April 24, 2015

CMS Posts Sample Notice To Beneficiaries Regarding Appeal Rights

CMS has posted the following notice regarding MSP Appeal Rights under the SMART Act. Under the process the the Social Security Beneficiary is only a party of notice and the the direct parties become the Insurance Carrier or Workers' Compensation Entity who initiates the appeal. The process has yet to unfold when an injured workers moves for standing to appear and participate in the process.

On February 27, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule implementing certain provisions of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART ACT). This final rule establishes a formal appeals process for applicable plans (liability insurance (including self-insurance), no-fault insurance, and workers’ compensation laws or plans) in situations where the Secretary seeks Medicare Secondary Payer (MSP) recovery directly from an applicable plan. The rule is effective April 28, 2015, and applies to demand letters issued on or after April 28, 2015.

Beneficiaries will be notified in writing if an item or service they received is the subject of an appeal by the insurer or workers’ compensation entity.

A new document titled Appeals Process for Insurers and Workers’ Compensation Entities and Required Notice to Medicare Beneficiaries has been loaded to the downloads section of the What’s New page on the Beneficiary Services section of CMS.gov. The following link can be used to access the main page http://go.cms.gov/beneficiary. Once on the main page click the “What’s New” link in the left side menu and scroll to the bottom of the page.

Click here to see the sample notification to beneficiary form

Tuesday, April 21, 2015

CMS will be presenting a webinar on “Applicable Plan” Appeals

“Applicable Plan” Appeals Webinar – April 28, 2015

CMS will be presenting a webinar on “Applicable Plan” Appeals.

The term “applicable plan” means liability insurance (including self-insurance), no-fault insurance and workers’ compensation laws or plans. Effective for recovery demand letters issued directly to applicable plans as the identified debtor on or after April 28, 2015, applicable plans have formal appeal rights.

The presentation will include:
-an introduction to the appeals process (as the process is new to applicable plans), information on the appeals process specific to applicable plans, and
-tips/suggestions to applicable plans regarding the recovery process, including appeals.

Date: April 28, 2015 Start time: 1:00 PM Eastern time.

URL: https://webinar.cms.hhs.gov/r2g9kffqc46/

Please begin logging in approximately 15 minutes before the start time, due to the large number of participants

Wednesday, August 6, 2014

Third Circuit Court of Appeals Enforces Medicare Conditional Payment Collection

The Third Circuit Court of Appeals ruled that a Medicare recipient could not prevent CMS from recovering conditional payments from a liability settlement by holding that the NJ Collateral Source Statute (NJCSS) did not prevent Medicare from recovering medical expenses as part of her damages in a tort suit and that the state court's oder apportioning settlement proceeds did not bar the Federal government from seeking reimbursement for medical expenses.

Taransky v Sec of US HHS No. 13-3483, 214 WL 3719158 (Decided July 29, 2014)

Monday, August 4, 2014

CMS: "The Smarter Act" Introduced in the US Senate

From the folks that brought you The Smart Act comes the sequel, "The Smarter Act." Senator Bill Nelson (D-FL) on July 31, 2014 introduced, S.2731 - "A bill to amend title XVIII of the Social Security Act to provide for the application of Medicare secondary payer rules to certain workers' compensation settlement agreements and qualified Medicare set-aside provisions."

As you recall, since the Medicare Secondary Payer (MSP) was enacted in November 1980 to stop workers' compensation insurance carriers from shifting costs onto US taxpayers, there has been a constant volley of activity between the Federal government, and those who want to maintain a status quo, ie. employers, insurance carriers and "other" financially interested participants.

Congress and Medicare (Centers for Medicare and Medicaid Services [CMS]), in an effort to shore up the financially ailing Medicare program has been dueling with an employer/insurance company led coalition. The coalition successfully lobbied for The Smart Act in May 2003. Mandated regulations were published and the stakeholders, including the coalition partners filed multiple comments objecting to the process.

Purportedly S.2731 requires CMS to establish criteria: for review, calculations, time periods, appeals process, delivery of reimbursement, and immunity form retroactive laws/regulations.

The latest round of coalition supported legislation is yet another attempt to curb the tidal wave that continues to erode the workers' compensation program as it historically existed since 1911 in the US.

The real challenge to workers' compensation and its potential extinction, is whether the visionaries can look forward instead of backward. The future will be solutions to Medicare's fiscal integrity, the integration of the Affordable Care Act, preventive health care, safer workplaces and globalization of the Social Security Disability Insurance (SSDI) system.

Tuesday, July 22, 2014

CA DWC Issues Notice of Public Hearing on September 3 for Proposed Workers’ Comp Benefit Notice Regulations Amendments

Today's post was shared by WC CompNewsNetwork and comes from workerscompensation.com

San Francisco, CA (WorkersCompensation.com) - The Division of Workers' Compensation (DWC) has issued a notice of public hearing on proposed amendments to the Workers’ Compensation Benefit Notice regulations found in California Code of Regulations, title 8, sections 9810, 9811, 9812, 9813, 9814, 9815, 9881.1 and 10139.
Formal notice of this rulemaking proceeding will be published in today’s California Regulatory Notice Register. A public hearing on the proposed regulations has been scheduled at 10 a.m., September 3 in the auditorium of the Elihu Harris State Office Building at 1515 Clay Street, Oakland, CA 94612. If public comment concludes before the noon recess, no afternoon session will be held. Members of the public may submit written comments on the proposed regulations until 5 p.m. that day.
The rulemaking proposes to amend and update existing regulations requiring employers to serve notice on injured employees that they may be entitled to workers' compensation benefits. These notices deal with: the payment, nonpayment, or delay in payment of temporary disability, permanent disability, and death benefits; any change in the amount or type of benefits being provided; the termination of benefits; the rejection of any liability for compensation; and the requirement to provide an accounting of benefits paid. In addition, changes are also being proposed to the Notice to Employees Poster and the Notice of Potential Eligibility for Benefits and Claim Form.
The...

[Click here to see the rest of this post]

Found on

Monday, April 14, 2014

CMS Posts WCMSA Self-Administration Guidance

A new WCMSA Self-Administration page has been added to the Workers Compensation Medicare Set-Aside Arrangement section of CMS.gov. The new page contains information for individuals who choose to self-administer their WCMSA accounts. Materials available on the new page include:

New Self-Administration Toolkit for WCMSAs
Account Expenditure for Lump Sum Account (Attestation Letter)
Account Expenditure for Structured Annuity (Attestation Letter)
Transaction Record Sample
WCMSA Reference Guide

The following link may be used to access the page http://go.cms.gov/WCMSASelfAdm.

Related Articles:

Workers' Compensation: New WCMSA Reference Guide is ...

Nov 07, 2013

An updated Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide is now available in the Downloads section found at the bottom of this page. This version documents the current WCMSA ...

http://workers-compensation.blogspot.com/

CMS Announces New WCMSA Re-Evaluation Procedure

Feb 21, 2013

Effective immediately, if a WCMSA proposal amount was originally submitted via the web-portal, a re-evaluation of an approved WCMSA amount can be requested through the WCMSA web portal, if the claimant or submitter ...

http://workers-compensation.blogspot.com/

CMS Hosting a Town Hall Event for WCMSA - Workers ...

Apr 02, 2013

The CMS will be hosting a WCMSA teleconference on April 11, 2013. This event will provide stakeholders an opportunity to learn more about the Workers' Compensation Review Contractor (WCRC), and discuss procedural ...

http://workers-compensation.blogspot.com/

Annual Reporting of WCMSA Account Expenditures

Jan 03, 2012

Please send your completed annual Workers' Compensation Medicare Set-aside Arrangement (WCMSA) Account Expenditure accounting documentation to the CMS lead Medicare Contractor at the address below: MSPRC ...

http://workers-compensation.blogspot.com/

Tuesday, February 18, 2014

Just Published: 2014 Update - Gelman on Workers' Compensation Law

Jon Gelman’s newly revised and updated treatise on Workers’ Compensation Law has just been published by West Group of Egan, MN. The treatise is the most complete work available on NJ Workers’ Compensation law.

The work offers an in-depth and insightful analysis that provides a quick and accurate guidance to those who practice workplace injury law. Time-saving comments and instructions shorten the claims process and expedite handling of issues.

New areas of the law reviewed:

The newly enacted SMART Act (The Strengthening Medicare and Repaying Taxpayers Act of 2012), and the proposed Regulations, are discussed at length in this supplement. The newly enacted statutory provision concerning balance billing and expanded jurisdiction of the Workers’ Compensation Court is reviewed. The launch of COURTS 4, the expanded workers’ compensation electronic filing system, implementing e-filing of Notice of Motions, is explained along with accompanying sample forms, codes, and instructions for filing/service. The statutory extension of lifetime benefits embodied in recent legislation for surviving spouses of police and fire department employees, who are fatally injured in-the-line of duty, is discussed. The recent case law concerning the second-prong of the “context test” involving the “Exclusivity Doctrine” is reviewed

New 2014 Section Sections include:

--Dependency—Surviving spouse of police or fire department killed in the line of duty [12.14.50]

--Case organization utilization reporting tracking system (COURTS)—Court proceeding type codes [25.22.30]

--Case organization utilization reporting tracking system (COURTS)—E-filing of motions—General motion [25.22.40]

Gelman on Workers’Compensation Law is exclusively integrated into the entire world-wide leading legal research network of West Group-Reuters-Thomson publications.

It is now available, in print, on CD-Rom and online via Westlaw™ and WestlawNext™. [Westlaw Database Identifier NJPRAC]

Click here now to order your copy.

Jon L. Gelman is nationally recognized as an author, lecturer and skilled trial attorney in the field of workers’ compensation law and occupational/environmental disease litigation. Over a career spanning more than three decades he has been involved in complex litigation involving thousands of clients challenging the mega-industries of: asbestos, tobacco and lead paint. Gelman is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). He is the former Vice-President of The Workers Injury Law & Advocacy Group (WILG) and a charter member of The College of Workers' Compensation Lawyers. Jon is a founder of the Nancy R. Gelman Foundation Inc., which seeks to fund innovative research to cure breast cancer. He is also an avid photographer. jon@gelmans.com -www.gelmans.com

Sunday, January 5, 2014

Comments Medicare Program: Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal

Comments submitted concerning the Medicare Program: Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal are now available for review.

Summary

This interim final rule with comment period specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act). The interim final rule specifies a timeline for developing a multifactor authentication solution to securely permit authorized users other than the beneficiary to access CMS' MSP conditional payment amounts and claims detail information via the MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that permits users to: notify us that the specified case is approaching settlement; obtain time and date stamped final conditional payment summary forms and amounts before reaching settlement; and ensure that relatedness disputes and any other discrepancies are addressed within 11 business days of receipt of dispute documentation.

Docket ID:CMS-2013-0199

Topic(s):Kidney Diseases, Medicare, Physician Referral, Reporting and Recordkeeping Requirements

Document Type:Rule

Received Date:Sep 20, 2013

Start-End Page:57800 - 57806

Comment Start Date:Sep 20, 2013

Comment Due Date:Nov 19, 2013

Comments submitted included those of:

-Progressive Medical

-AAJ

-Property Casualty Insurers of America

-Crowe Paradis

-Franco Signor

-MARC

-CA State Compensation Fund

-NAMSAP

-DRI

-Allsup

-RIMS

-FCC

-Garretson Resolution Group

-AIA

-UWC

Click here to view all contents individually.

Found on

Thursday, November 7, 2013

New WCMSA Reference Guide is Now Available

An updated Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide is now available in the Downloads section found at the bottom of this page. This version documents the current WCMSA review process and provides more detailed information on the actions performed by the Workers’ Compensation Recovery Contractor (WCRC).

CMS is currently working on additional enhancements to the WCMSA process. Stakeholders will be notified of these proposed changes prior to implementation. Please continue to monitor the WCMSA website for updates.

The following sections of the Guide have been enhanced or added:

9.4.1.1 – Most Frequent Reasons for Development Requests: The five most common omissions as provided by the WCRC.
9.4.2 – WCRC Team Background and Resources Used: The expertise of the WCRC reviewers as well as the resources used when reviewing a WCMSA.
9.4.3 – WCRC Review Considerations: Examples of the questions and factors that guide the WCRC’s review of WCMSA proposals. The overarching guidelines used in treatment allocations and pricing is also provided.
9.4.4 – Medical Review: A diagram and steps the WCRC follows in its medical review process with a general explanation of documentation requirements.
9.4.5 – Medical Review Guidelines: Considerations and examples in specific medical cases and topics.
9.4.6.1 – Prescription Drug Review: Details the process the WCRC follows in reviewing prescription medication allocations and the resources that may be used.
9.4.6.2 – Pharmacy Guidelines and Conditions: Discusses specific drug usage and pricing considerations.
10.1.8 – Pay history added to list of information needed for WCMSA submission.

Click here to read the guide.

Friday, September 27, 2013

Lobbying In D.C. On Behalf Of Injured Workers

Regulations were proposed recently to operationalize the The SMART act. The public comment period is ongoing. Today's post comes from guest author Paul J. McAndrew, Jr., from Paul McAndrew Law Firm.

On April 17, my colleagues from WILG (Workers Injury Law & Advocacy Group) and I gathered in Washington D.C. to lobby Congressional representatives on behalf of injured workers. We discussed several bills that will affect the interests of workers in Iowa and across the United States. I had the pleasure of meeting with Senator Tom Harkin, Senator Chuck Grassley, Congressman Bruce Braley and Congressman Dave Loebsack in their offices where we discussed the following bills:

The MSP and Workers’ Compensation Settlement Agreement Act of 2012

The Akaka Amendment to S. 1789, The Post Service Reform Bill (an amendment to strip from S. 1789 those provisions that deform the Federal Employee Compensation Act).

As I explained at these meetings, the MSP and Worker’s Compensation Settlement Act of 2012 is necessary for three reasons:
(1) to bring some reasonable and understandable system to CMS’ current uncertain and regulation-less system of establishing Medicare Set-aside Plans for workers’ compensation settlements;
(2) to allow for an appeal of CMS’s MSA determination; and
(3) to bring some reasonable time limits to CMS’ process of setting the MSA required for workers’ compensation settlements.

The Akaka Amendment to strip the FECA deform provisions out of S.1789 is necessary because the FECA deform provisions wrongfully reduces monetary benefits and treats the injured worker like a fraud (mandating period independent medical examinations, vocational rehabilitation and field nurses to hound the injured worker). Workers' compensation reform is a constant threat to the rights of workers across the country. It is important that all of us who participate in the work' comp' system do our part to protect and preserve these legal rights.

Found on

Monday, September 23, 2013

CMS Publishes Rules to MSP Payments Under the SMART Act

Medicare has published proposed Rules to governor obtaining information concerning the conditional payments as required by the recently implemented SMART Act. The Regulations expand the bureaucratic framework for Medicare beneficiaries and their representatives in order to obtain and appeal information on condition payment demands from the government.

The Rules are effective on November 10, 2013 and the comment period closes at 5pm on that date.

The government will be establishing a multifactorial implementation process to keep information secure: DX Codes, provider names. dates of service and conditional payment amounts. Ultimately, it appears that the process will be yet another hurdle to obtain information for workers' compensation claims and release the beneficiary from government liability for medical expenses.

The proposed CMS Rules can be reviewed at: https://www.federalregister.gov/articles/2013/09/20/2013-22934/medicare-program-obtaining-final-medicare-secondary-payer-conditional-payment-amounts-via-web-portal

….

Jon L. Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). For over 4 decades the Law Offices of Jon L Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.

US Supreme Court Asked to Review MSP Preemption Issue (workers-compensation.blogspot.com)
9th Circuit Vacates MSP Injunction Against CMS for Medicare Reimbursement (workers-compensation.blogspot.com)
Medicare To Punish 2,225 Hospitals For Excess Readmissions (workers-compensation.blogspot.com)
The Public and the Conflict over Future Medicare Spending (workers-compensation.blogspot.com)
Democrats Jump on the 'Death Panel' Bandwagon (workers-compensation.blogspot.com)

Thursday, September 5, 2013

9th Circuit Vacates MSP Injunction Against CMS for Medicare Reimbursement

The 9th Circuit Court of Appeals has vacated a Federal District Court Order enjoying CMS from seeking reimbursement for Medicare Conditional Payments under the Medicare Secondary Payer Act (MSP).

The Court held that it lacked jurisdiction:

"... we conclude that the
beneficiaries' claim was not adequately presented to the
agency at the administrative level and therefore the district
court lacked subject matter jurisdiction pursuant to 42 U.S.C.§ 405(g) .

***

" Federal question jurisdiction does not extend to most
claims arising under the Medicare Act. The Medicare Act
incorporates 42 U.S .C. § 405(h) , which provides:
No findings of fact or decision of the
[Secretary] ... shall be reviewed by
any person, tribunal, or governmental
agency except as herein provided.
No action against the United States,
the [Secretary] ..., or any officer or
employee thereof shall be brought
under section 1331 ... of title 28 torecover on any claim arising under this
subchapter.
42 U.S.C. § 405(h) ; 42 U.S.C. § 1395ii .

****

"We decline to adopt the extraordinarily broad reading of
Eldridge that the beneficiaries invite. We conclude that the
named plaintiffs' reimbursement disputes did not provide an
opportunity for the Secretary to consider the claim that her
interpretation of the secondary payer provisions exceeded
her authority. Their requests for redetermination of their
respective amounts of reimbursement did not constitute
presentment of their policy challenge.

***

" We conclude that the beneficiaries' claim was
not presented to the agency. Because presentment is a
jurisdictional requirement under § 405(g) , the district court
lacked subject matter jurisdiction over the beneficiaries'
claim.

Haro v Sebelius, ___F.3d____, No. 11-16606, 2013 WL 4734032, Decided Sept.4, 2013.

Read prior posting about this case:

Federal Court Enjoins CMS From MSP Recovery Procedures

May 18, 2011

Haro v. Sebelius, 2010 WL 1452942 (A. Ariz.) CV 09-134 TUC DCB, Decided April 12, 2010.The plaintiffs were permitted discovery beyond the administrative record. The class action is challenging the recovery procedures of ...

http://workers-compensation.blogspot.com/

Workers' Compensation: Halted: Medicare Secondary Payer ...

May 25, 2011

The MSPRC is still working cases, and the RAR and Demand letters will be mailed out once appropriate revisions have been made." This follows a recent US District Court ruling enjoining CMS's collection procedures. Haro v.

http://workers-compensation.blogspot.com/

….

Thursday, August 22, 2013

US Supreme Court Asked to Review MSP Preemption Issue

The US Supreme Court has been asked to review a claim on behalf of an injured worker who asserts that the Medicare Secondary Payer Act did not preempt State law (i.e.. Texas) that required a Workers' Compensation claimant to obtain preauthorization from relevant insurance carriers before incurring certain medical expenses. The Fifth Circuit Court of Appeals held that Medicare's conditional payment for a workers surgeries did not render the state law mandate for preauthorization requirements "moot."

A Writ of Certiorari was filed with the US Supreme Court on Aug. 8, 2012 and a response is due September 11, 2013

Guadalupe Caldera v. Insurance Company of the State of Pennsylvania, US Supreme Court Docket No. 12-40192. Case below, 716 F 3d 861, Docket No, 12-40192, 5th Cir Ct Appeals, Decided May 14, 2013.

….

Jon L.Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). For over 4 decades the Law Offices of Jon L Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.

CMS Releases Revised List of Workers Compensation Set-Aside Contacts

The Centers for Medicare and Medicaid Services has released a revised list of contacts for Workers' Compensation Set-Aside Contacts. The contacts have been centralized in 6 areas of the US.

Click here to download the PDF version of the revised list of contacts.

Copyright

Friday, September 30, 2016

Tuesday, May 17, 2016

Monday, October 5, 2015

Related articles

Thursday, July 9, 2015

Related articles

Monday, June 1, 2015

Related articles

Thursday, May 28, 2015

Related articles

Friday, April 24, 2015

Tuesday, April 21, 2015

Related articles

Wednesday, August 6, 2014

Related articles

Monday, August 4, 2014

Related articles

Tuesday, July 22, 2014

Related articles

Monday, April 14, 2014

Tuesday, February 18, 2014

Sunday, January 5, 2014

Related articles

Thursday, November 7, 2013

Related articles

Friday, September 27, 2013

Related articles

Monday, September 23, 2013

Related articles

Thursday, September 5, 2013

Related articles

Thursday, August 22, 2013

Monday, August 12, 2013

Related articles