A NJ Superior Court deemed a proposed Medicare Set-Aside Agreement to be satisfactory to protect Medicare's interests and granted a Motion to Enforce a Pending Settlement. This action by the Court was taken after CMS (Centers for Medicare & Medicaid Services) declined to rule on the adequacy of the Set Aside Agreement because of limited Federal resources.
"The court has thoroughly reviewed the sworn testimony of plaintiffs' expert regarding the proposed set-aside amounts for future medical expenses relating to the
underlying accidents/incidents, which would otherwise be covered or reimbursable
by Medicare. The court finds that the proposed set-aside amount in each case
fairly takes Medicare's interests into account in that the figures are both reasonable and reliable. Therefore, the court is satisfied that Medicare's interests
have been adequately protected pursuant to the MSP. Plaintiffs shall set aside the
proposed sums in self-administered interest-bearing accounts to be used solely for
the purpose of satisfying future medical expenses related to the underlying accidents/incidents."
DUHAMELL, Plaintiff v. RENAL CARE GROUP EAST, INC., RCG Southern New Jersey, LLC, Philadelphia Suburban Development Corporation, Defendants. Catherine A. Ney, Plaintiff, et al,, --- A.3d ----, 2013 WL 2102701 (N.J.Super.A.D.) Decided Dec. 7, 2012. May 16, 2013.
Showing posts with label Centers for Medicare and Medicaid Services. Show all posts
Showing posts with label Centers for Medicare and Medicaid Services. Show all posts
Saturday, May 18, 2013
Saturday, December 29, 2012
Class Action by Medicare Advantage Beneficiares Dismissed By Federal Court
A federal class action, by a group of plaintiffs who alleged that they were a class of Medicare-eligible individuals enrolled in a Medicare Advantage plan, and received benefits under part C of the Medicare program, was dismissed by a federal court under the preemption doctrine. In an action removed to Federal court, the plaintiffs sought to bring a class action in state court alleging that New York state law applied regarding reimbursement for for monetary settlements from third-party tortfeasors.
The court ruled that the interpretation of the secondary payer provision of Medicare part C, 42 USC section 1395W-22 (a)(4), preempted any state law provisions.
Meek-Horton v. Trover Solutions, Inc., No. 11 CV 6054(RPP), 2012 WL 6699776, (SD-NY 2012) Decided December 26, 2012
Read more about "The Medicare Secondary Payer Act" and workers' compensation
The court ruled that the interpretation of the secondary payer provision of Medicare part C, 42 USC section 1395W-22 (a)(4), preempted any state law provisions.
Meek-Horton v. Trover Solutions, Inc., No. 11 CV 6054(RPP), 2012 WL 6699776, (SD-NY 2012) Decided December 26, 2012
Read more about "The Medicare Secondary Payer Act" and workers' compensation
Oct 01, 2012
US Supreme Court Denies CMS-MSP Case - Hadden. 2012 WL 1106757. Supreme Court of the United States. HADDEN, VERNON V. UNITED STATES. No. 11-1197.Oct. 1, 2012. Opinion. The petition for writ of certiorari is ...
Dec 28, 2012
CMS/MSP Requires Deceased Beneficiary Information. CMS has announced that workers' compensation information concerning deceased beneficiaries must be reported by insurance carriers. "We received another question ...
Apr 03, 2009
CMS/MSP Requires Deceased Beneficiary Information. CMS has announced that workers' compensation information concerning deceased beneficiaries must be reported by insurance carriers. "We received another question ...
May 18, 2011
"IT IS FURTHER ORDERED that Defendant's demand for payment of her MSP reimbursement claims, under threat of collection actions before there has been a resolution of an appeal regarding the amount of the Defendant's ...
Tuesday, January 3, 2012
Annual Reporting of WCMSA Account Expenditures
Address for submitting annual accounting documentation to CMS' Medicare Secondary Payer Recovery Contractor (MSPRC). 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 - Non-Group Health Plan (NGHP)
P.O. Box 138832
Oklahoma City, OK 73113
Tuesday, November 22, 2011
The Doctrine of Equitable Allocation Not Applicable in a Medicare Secondary Payment Reimbursement Claim
The 6th Circuit Court of Appeals has ruled that The Center for Medicare and Medicaid Services (CMS) is entitle to complete reimbursement of Medicare payments under the Medicare Secondary Payer Act (MSP) from a liability claim even though the beneficiary claimed that the settlement required allocation due to the law allocating liability.
"We address only one of them here: specifically, under § 1395y(b)(2)(B)(ii) as amended, if a beneficiary makes a “claim against [a] primary plan[,]” and later receives a “payment” from the plan in return for a “release” as to that claim, then the plan is deemed “responsib [le]” for payment of the “items or services included in” the claim. Id. Consequently, the scope of the plan's “responsibility” for the beneficiary's medical expenses—and thus of his own obligation to reimburse Medicare-is ultimately defined by the scope of his own claim against the third party. That is true even if the beneficiary later “compromise[s]” as to the amount owed on the claim, and even if the third party never admits liability. And thus a beneficiary cannot tell a third party that it is responsible for all of his medical expenses, on the one hand, and later tell Medicare that the same party was responsible for only 10% of them, on the other."
Hadden v. U.S., --- F.3d ----, 2011 WL 5828931, C.A.6 (Ky.), 2011. Decided November 21, 2011.
For over 3 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.
Saturday, October 22, 2011
Government Appeals Case Involving MSP Statute of Limitations
The case was tried in the U.S. District Court, Northern District of Alabama (Eastern) before Judge Karon O. Bowdre and involved a contract reimbursement claim under the Medicare Act, specifically 425 USC 1395 (HHS). A Final Order was entered on September 13, 2011 the the United States filed a Notice of Appeal on October 11, 2011.
Read the prior posting: CMS Has 6 Year Statute of Limitations-Court Dismisses MSP Recovery Claim 10.1.2010
United States of America v James J. Stricker, et al., CV 09-BE-2423-E (USDCT ND Alabama)
Sunday, October 2, 2011
New CMS Policy Announced: Asbestos Exposure, Ingestion, and Implantation Issues and December 5, 1980
The Centers for Medicare & Medicaid Services has consistently applied the Medicare Secondary Payer (MSP) provision for liability insurance (including self-insurance) effective 12/5/1980. As a matter of policy, Medicare does not assert a MSP liability insurance based recovery claim against settlements, judgments, awards, or other payments, where the date of incident (DOI) occurred before 12/5/1980.
When a case involves continued exposure to an environmental hazard, or continued ingestion of a particular substance, Medicare focuses on the date of last exposure or ingestion for purposes of determining whether the exposure or ingestion occurred on or after 12/5/1980. Similarly, in cases involving ruptured implants that allegedly led to a toxic exposure, the exposure guidance or date of last exposure is used. For non-ruptured implanted medical devices, Medicare focuses on the date the implant was removed. (Note: The term “exposure” refers to the claimant’s actual physical exposure to the alleged environmental toxin, not the defendant’s legal exposure to liability.)
In the following situations, Medicare will assert a recovery claim against settlements, judgments, awards, or other payments, and the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Section 111 MSP mandatory reporting rules must be followed:
• Exposure, ingestion, or the alleged effects of an implant on or after 12/5/1980 is claimed, released, or effectively released.
• A specified length of exposure or ingestion is required in order for the claimant to obtain the settlement, judgment, award, or other payment, and the claimant’s date of first exposure plus the specified length of time in the settlement, judgment, award or other payment equals a date on or after 12/5/1980. This also applies to implanted medical devices.
• A requirement of the settlement, judgment, award, or other payment is that the claimant was exposed to, or ingested, a substance on or after 12/5/1980. This rule also applies if the settlement, judgment, award, or other payment depends on an implant that was never removed or was removed on or after 12/5/1980.
When ALL of the following criteria are met, Medicare will not assert a recovery claim against a liability insurance (including self-insurance) settlement, judgment, award, or other payment; and MMSEA Section 111 MSP reporting is not required. (Note: Where multiple defendants are involved, the claimant must meet all of these criteria for each individual defendant in order for a settlement, judgment, award, or other payment from that defendant to be exempt from a potential
MSP recovery claim and MMSEA Section 111 reporting):
•All exposure or ingestion ended, or the implant was removed before 12/5/1980; and
•Exposure, ingestion, or an implant on or after 12/5/1980 has not been claimed and/or specifically released; and,
•There is either no release for the exposure, ingestion, or an implant on or after 12/5/1980; or where there is such a release, it is a broad general release (rather than a specific release), which effectively releases exposure or ingestion on or after 12/5/1980. The rule also applies if the broad general release involves an implant.
For Specific Examples Click Here To Read the CMS Memo
REPORTING REMINDER:
Information related to the MMSEA Section 111 MSP reporting requirements can be found at
www.cms.hhs.gov/MandatoryInsRep. When reporting a potential settlement, judgment, award, or other payment related to exposure, ingestion, or implantation, the date of first exposure/date of first ingestion/date of implantation is the date that MUST be reported as the DOI. This is true for purposes of individual self-identification of a pending claim to the Centers for Medicare & Medicaid Services’ Coordination of Benefits Contractor, as well as for MMSEA Section 111 reporting.
Related articles
When a case involves continued exposure to an environmental hazard, or continued ingestion of a particular substance, Medicare focuses on the date of last exposure or ingestion for purposes of determining whether the exposure or ingestion occurred on or after 12/5/1980. Similarly, in cases involving ruptured implants that allegedly led to a toxic exposure, the exposure guidance or date of last exposure is used. For non-ruptured implanted medical devices, Medicare focuses on the date the implant was removed. (Note: The term “exposure” refers to the claimant’s actual physical exposure to the alleged environmental toxin, not the defendant’s legal exposure to liability.)
• Exposure, ingestion, or the alleged effects of an implant on or after 12/5/1980 is claimed, released, or effectively released.
• A specified length of exposure or ingestion is required in order for the claimant to obtain the settlement, judgment, award, or other payment, and the claimant’s date of first exposure plus the specified length of time in the settlement, judgment, award or other payment equals a date on or after 12/5/1980. This also applies to implanted medical devices.
• A requirement of the settlement, judgment, award, or other payment is that the claimant was exposed to, or ingested, a substance on or after 12/5/1980. This rule also applies if the settlement, judgment, award, or other payment depends on an implant that was never removed or was removed on or after 12/5/1980.
When ALL of the following criteria are met, Medicare will not assert a recovery claim against a liability insurance (including self-insurance) settlement, judgment, award, or other payment; and MMSEA Section 111 MSP reporting is not required. (Note: Where multiple defendants are involved, the claimant must meet all of these criteria for each individual defendant in order for a settlement, judgment, award, or other payment from that defendant to be exempt from a potential
MSP recovery claim and MMSEA Section 111 reporting):
•All exposure or ingestion ended, or the implant was removed before 12/5/1980; and
•Exposure, ingestion, or an implant on or after 12/5/1980 has not been claimed and/or specifically released; and,
•There is either no release for the exposure, ingestion, or an implant on or after 12/5/1980; or where there is such a release, it is a broad general release (rather than a specific release), which effectively releases exposure or ingestion on or after 12/5/1980. The rule also applies if the broad general release involves an implant.
For Specific Examples Click Here To Read the CMS Memo
REPORTING REMINDER:
Information related to the MMSEA Section 111 MSP reporting requirements can be found at
www.cms.hhs.gov/MandatoryInsRep. When reporting a potential settlement, judgment, award, or other payment related to exposure, ingestion, or implantation, the date of first exposure/date of first ingestion/date of implantation is the date that MUST be reported as the DOI. This is true for purposes of individual self-identification of a pending claim to the Centers for Medicare & Medicaid Services’ Coordination of Benefits Contractor, as well as for MMSEA Section 111 reporting.
Related articles
Friday, September 30, 2011
CMS Announced Status Update and Future Changes
As part of the Centers for Medicare & Medicaid Service (CMS) efforts to continuously improve its Medicare Secondary Payer (MSP) program; CMS has posted the following information to the MSP websites:
1) An ALERT delaying the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Section 111 MSP reporting requirement for certain liability insurance (including self-insurance) settlements, judgments, awards, or other payments is now posted at www.cms.gov/MandatoryInsRep.
2) Policy guidance related to Exposure, Ingestion, and Implantation issues, and December 5, 1980, is now posted at www.cms.gov/MandatoryInsRep and www.cms.gov/COBGeneralInformation.
3) An ALERT related to Qualified Settlement Funds, under Section 468B of the Internal Revenue Code, is now posted at www.cms.gov/MandatoryInsRep.
4) A policy memorandum, for liability insurance (including self-insurance), on the acceptance of the treating physician's certification, and its impact on the issue of protecting Medicare's interests with respect to future medicals is now posted at www.cms.gov/COBGeneralInformation.
In addition, on September 30, 2011, the MSPRC will implement a self-service information feature to its customer service line. This feature gives callers the ability to get the most up-to-date Demand/Conditional Payment amounts, and the dates that those letters were issued, without having to speak to a customer service representative. The self-service feature will be available for extended hours, and callers will have the option of requesting information on multiple cases during one phone call.
Beginning in October 2011, CMS will implement an option to pay a fixed percentage of certain physical trauma-based liability cases with settlement amounts of $5000 or less. Detailed information on this option will be posted as an ALERT, on or before October 21, 2011, on the MSPRC website at www.MSPRC.info.
Upcoming improvements to the MSP program, expected within the next 3-9 months, include the following:
• The implementation of a MSPRC portal, where the beneficiary/representative can obtain information about Medicare's claim payments, demand letters, etc., and input information related to a settlement, disputed claims, etc.
• The implementation of an option that allows for an immediate payment to Medicare for future medical costs that are claimed/released/effectively released in a settlement.
• The implementation of a process that provides Medicare's conditional payment amount, prior to settlement in certain situations.
1) An ALERT delaying the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Section 111 MSP reporting requirement for certain liability insurance (including self-insurance) settlements, judgments, awards, or other payments is now posted at www.cms.gov/MandatoryInsRep.
2) Policy guidance related to Exposure, Ingestion, and Implantation issues, and December 5, 1980, is now posted at www.cms.gov/MandatoryInsRep and www.cms.gov/COBGeneralInformation.
3) An ALERT related to Qualified Settlement Funds, under Section 468B of the Internal Revenue Code, is now posted at www.cms.gov/MandatoryInsRep.
4) A policy memorandum, for liability insurance (including self-insurance), on the acceptance of the treating physician's certification, and its impact on the issue of protecting Medicare's interests with respect to future medicals is now posted at www.cms.gov/COBGeneralInformation.
In addition, on September 30, 2011, the MSPRC will implement a self-service information feature to its customer service line. This feature gives callers the ability to get the most up-to-date Demand/Conditional Payment amounts, and the dates that those letters were issued, without having to speak to a customer service representative. The self-service feature will be available for extended hours, and callers will have the option of requesting information on multiple cases during one phone call.
Beginning in October 2011, CMS will implement an option to pay a fixed percentage of certain physical trauma-based liability cases with settlement amounts of $5000 or less. Detailed information on this option will be posted as an ALERT, on or before October 21, 2011, on the MSPRC website at www.MSPRC.info.
Upcoming improvements to the MSP program, expected within the next 3-9 months, include the following:
• The implementation of a MSPRC portal, where the beneficiary/representative can obtain information about Medicare's claim payments, demand letters, etc., and input information related to a settlement, disputed claims, etc.
• The implementation of an option that allows for an immediate payment to Medicare for future medical costs that are claimed/released/effectively released in a settlement.
• The implementation of a process that provides Medicare's conditional payment amount, prior to settlement in certain situations.
Wednesday, August 10, 2011
Qui Tam Action for MSP Results in Costs to Plaintiff
A Federal court ruled that a plaintiff acted with an improper purpose and in bad faith by filing seven different putative qui tam actions against various health care providers under the Medicare Secondary payer Act (MSP). The Federal Court imposed sanctions against plaintiff pursuant to court's inherent power.
The Court reasoned that there was no legal support for plaintiff's claim that MSP was a qui tam statute, Court of Appeals had previously determined that plaintiff's claims were “utterly frivolous” and “unreasonable and vexatious,” and plaintiff had already filed dozens of almost identical cases across the country with similar results.
Stalley ex rel. U.S. v. Mountain States Health Alliance, 644 F.3d 349, C.A.6 (Tenn.), 2011, decided July 08, 2011
Related articles
The Court reasoned that there was no legal support for plaintiff's claim that MSP was a qui tam statute, Court of Appeals had previously determined that plaintiff's claims were “utterly frivolous” and “unreasonable and vexatious,” and plaintiff had already filed dozens of almost identical cases across the country with similar results.
Stalley ex rel. U.S. v. Mountain States Health Alliance, 644 F.3d 349, C.A.6 (Tenn.), 2011, decided July 08, 2011
Related articles
Monday, August 8, 2011
Workers' Compensation Medicare Set-Aside Web Portal (WCMSAP) Webinar
Please read below an invitation to Submitters to attend a CMS Workers' Compensation Medicare Set-Aside Web Portal (WCMSAP) Webinar.
WCMSAP Submitters Webinar - August 10, 2011
Event Description: This Webinar will review the Workers' Compensation Medicare Set-Aside Portal (WCMSAP), a new web-based application that allows for the electronic submission and tracking of WCMSA proposals submitted to CMS for review. This Webinar will also review the current WCMSA proposal submission process, the new submission process on the WCMSAP and the WCMSAP screens that will be used to enter and submit a proposal.
Enrollment Information: To receive your Webinar access information simply send an email to Techi@nhassociates.net and include the following information. To ensure that you receive webinar access information, future notifications and announcements regarding the Webinar, please add this e-mail address (Techi@nhassociates.net) to your "Safe Sender" list in your e-mail client.
Note: Due to limited seating we will need to hold attendance to an 85 user maximum. So please reserve
your seat as soon as possible, we apologize for any inconvenience.
Information Required for WCMSAP Webinar Registration:
Name (first and last):
Email Address:
Company Name:
Tel. Number:
Receipt of invitation which reserves space in Outlook Calendar (i.e. an iCal) (Yes/No):
Tuesday, July 26, 2011
7 Problems Facing Work Comp in a Credit Default
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| White House Photo, Pete Souza, 7/25/11 |
The consequences of a US credit default will be significant. President Obama stated, "If that happens, and we default, we would not have enough money to pay all of our bills -– bills that include monthly Social Security checks, veterans’ benefits, and the government contracts we’ve signed with thousands of businesses. "
1. Centers for Medicare and Medicaid Services (CMS) and their contractor will be unable to provide conditional payment information under the Medicare Secondary Payer Act. Negotiations in workers compensation matters will come to halt.
2. CMS will be unable to approve compromises and releases in advance of workers' compensation disposition thereby halting the State systems.
3. CMS and their agents will be unable to review Medicare Set-Aside Agreements thereby stopping workers' compensation dispositions by compromise.
4. Chaos will erupt in those States where Social Security takes a reverse offset on permanency payments. Workers' compensation insurance companies and employers will become responsible for the entire amount to be paid.
5. The Veterans' Administration will be unable to provide information concerning medical treatment. Records will he held-up and will delay evaluations in adjudications in workers' compensation cases.
6. Tricare and other federal insurance providers will be unable to provide benefit information. The lack of reimbursement data will stymie evaluation of medica reimbursement issues slowing the disposition and settlements of workers' compensation claims.
7. The US Military will be unable to provide Personnel Records and prior medical treatment and claim information.
The potential fiscal impact of a US debt crisis is enormous. Hopefully, the politicians in Washington will reach a compromise and the this crisis will be resolved and everyone can creatively focus on making the compensation system less complicated and more efficient.
Friday, July 8, 2011
Workers’ Compensation Medicare Set-Aside Portal (WCMSAP)
The Centers for Medicare & Medicaid Services (CMS) is currently Pilot Testing the Workers' Compensation Medicare Set-aside Portal (WCMSAP), a web-based application. This new initiative will allow submitters of Workers' Compensation Medicare Set-Aside Arrangements (WCMSAs) to directly enter case information, upload documentation, and receive case status information through the use of a secure Web portal.
This secure Web portal will greatly improve the efficiency of the submission process for WCMSAs, including receipt of the proposal by its Workers' Compensation Review Contractor (WCRC). The WCMSAP, a web-based application, will allow 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
• Submit WCMSA cases
• Perform case lookups
• Append documentation to a case
Wednesday, June 22, 2011
Congress Told CMS Must Continue to Stop Work Comp Cost Shifting
At a House Oversight hearing today it was revealed that over the last decade the Centers for Medicare and Medicaid Service (CMS) has obtained over $50 Billion in reimbursement under the Medicare Secondary Payer Act (MSP). CMS has worked diligently to stop cost shifting from workers' compensation insurance carriers to the US taxpayer.
Ms. Taylor concluded by stating that, "...CMS is committed to a transparent MSP process that ensures that beneficiaries receive the care they need, while reducing Medicare payments for claims that are the legal responsibility of a group health plan, NGHP, or other responsible party. We understand that the MSP process can present challenges to all involved in coordination of benefits between Medicare and other payers. We are committed to maintaining a strong line of communication with beneficiaries, insurance and workers’ compensation plans, and other stakeholders on MSP policy in general, as well as the new Section 111 reporting requirements. Additionally, we will look to expand and strengthen our training and education opportunities where possible. CMS looks forward to working with our partners and beneficiaries in the future to preserve the integrity of the Medicare program and secure the Medicare Trust Funds for future generations. We look forward to working with Congress as well on these important goals."
- Medicare Secondary Payer: Process for Situations Involving Non-Group Health Plans, US GAO Study James C. Cosgrove, Director, Health Care - 6.22.11
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Monday, June 20, 2011
CMS Recovery Contractor Publishes New Rights and Responsibilities Letter
The Centers for Medicare and Medicaid Services (CMS) has now posted its newly revised Rights and Responsibilities letter. The letter complies with the Court's Order in Haro v. Sebelius which restrict the application of interest while an appeal is pending. The letter no longer demands that an attorney withhold settlement proceeds from a case.
CMS employs outside contractors to collect conditional payments that Medicare has paid and for which it is only secondarily responsible
"The Medicare Secondary Payer Recovery Contractor (MSPRC) protects the Medicare trust fund by recovering payments Medicare made when another entity had primary payment responsibility. The MSPRC accomplishes these goals under the authority of the Medicare Secondary Payer (MSP) Act. The MSPRC identifies and recovers Medicare payments that should have been paid by another entity as the primary payer either under a Group Health Plan (GHP) or as part of a Non-Group Health Plan (NGHP) claim which includes, but is not limited to Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers' Compensation. The MSPRC does not pursue supplier, physician, or other provider recovery'."
For over 3 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.
Related articles
CMS employs outside contractors to collect conditional payments that Medicare has paid and for which it is only secondarily responsible
"The Medicare Secondary Payer Recovery Contractor (MSPRC) protects the Medicare trust fund by recovering payments Medicare made when another entity had primary payment responsibility. The MSPRC accomplishes these goals under the authority of the Medicare Secondary Payer (MSP) Act. The MSPRC identifies and recovers Medicare payments that should have been paid by another entity as the primary payer either under a Group Health Plan (GHP) or as part of a Non-Group Health Plan (NGHP) claim which includes, but is not limited to Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers' Compensation. The MSPRC does not pursue supplier, physician, or other provider recovery'."
For over 3 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.
Related articles
Thursday, June 2, 2011
Should CMS be A Joint Payee in a Workers Comp Settlement?
How to reimburse The Centers for Medicare and Medicaid Services (CMS) is becoming a serious issue under the Medicare Recovery Act (MSP). Commonly know as Allocation Orders, these cases are emerging across the country and the Courts are denying attempts to merge the payments of the plaintiff's with that due to CMS.
In Zaleppa v Seiwell, 2010 PA Super 208, No. 2019 MDA 2009, Decided November 17, 2010, an appellate panel tossed out a request to have CMS named as a co-payee of the proceeds. Likewise, a Federal Court ruled that CMS's name should not appear on the same check as the one going to the plaintiffs ruling that the interests of the two parties were not similar. Bradley v Sebelius, 621 F.3d 1330 (11 Cir Ct Ap 2010) decided September 29, 2010.
Tuesday, May 31, 2011
Medicare to Partially Resume Workmens Comp Collection Letters
CMS has a statutory obligation to seek recovery of medical benefits that it has paid to beneficiaries in those matters where Medicare is not the primary insurance carrier responsible for medical care. CMS seeks to recovery the money that it has apid from the workers' compensation insurance carrier. The process has evolved where in CMS sends notice to the attorneys in the pending workers' compensation claim seeking reimbursement at the time of resolution of the workers' compensation claim.
The Medicare Secondary Payer Recovery Contractor (MSPRC) is contracted to issue a letter know as the "Review of the Rights and Responsibility Letter" (RAR). The MSPRC has announced that the RAR letters will resume in some format on or about June 10, 2010.
Related articles
Wednesday, May 25, 2011
Halted: Medicare Secondary Payer Recovery Contractor Demand Letters
The Medicare Recovery Contractor (MSPRC) has now posted a notice on its web site that, "...Issuance of the Rights and Responsibilities (“RAR”) and Demand letters has been temporarily suspended while these letters are under review. 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. Sebelius, (A. Ariz.) CV 09-134 TUC DCB
This follows a recent US District Court ruling enjoining CMS's collection procedures. Haro v. Sebelius, (A. Ariz.) CV 09-134 TUC DCB
Monday, May 23, 2011
CMS Announces Review is Only a Recommended Process for Set-Aside Agreements
The Centers for Medicare and Medicaid Services (CMS) has just announced a clarification of its prior memos concerning the review of Workers Compensation proposed Set Aside Agreements and also indicates that submission is an elective process.
"Submission of a WCMSA proposal to CMS for review and approval is a recommended process. There are no statutory or regulatory provisions requiring that a WCMSA proposal be submitted to CMS for review. However, if an entity chooses to use the WCMSA review process, CMS requests that it comply with the established policies and procedures referenced on its Web site. Claimants, employers, carriers, and their representatives should be encouraged regularly to monitor this dedicated workers’ compensation Web site for changes in policies and procedures."
CMS indicated that, "A WCMSA should not be submitted to CMS when the resolution of the workers’ compensation claim results in the medical portion of the claim is being left open." In the memo, CMS reiterates the threshold levels and eligibility for review criteria.
Related articles
Wednesday, May 18, 2011
Federal Court Enjoins CMS From MSP Recovery Procedures
A US District Court Judge in Arizona has certified a putative class, composed of a nationwide class of Medicare recipients challenging the recovery procedures utilized by The Centers for Medicare and Medicaid Services (CMS). The Court also issued an Order enjoining CMS from certain collection activities.
The issues reviewed by the court were:
"1) whether Defendant [CMS] can require prepayment of an MSP recovery claim before the correct amount is determined through the administrative appeal procedures, and
2) whether Defendant [CMS] can make plaintiffs' attorneys financially responsible if they do not hold or immediately turn over to the Defendant [CMS] their clients' litigation proceeds.
These questions involve a due process analysis, which consists of a three part balancing test:
1) the private interest affected;
2) the risk of erroneous deprivation and probable value of additional safeguards, and
3) the government or public interest in current procedures. "
Haro v. Sebelius, (A. Ariz.) CV 09-134 TUC DCB
This follows a broad discovery ordered issued by the Court a year ago. 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 CMS under the Medicare Secondary Payer Act (MSP). The discovery permitted will included depositions and expert evidence .
The Court Order enjoins CMS from certain actions:
"IT IS FURTHER ORDERED that Defendant's demand for payment of her MSP reimbursement claims, under threat of collection actions before there has been a resolution of an appeal regarding the amount of the Defendant's MSP claim or a waiver request, exceeds her authority under the Medicare statute, and Defendant is enjoined from demanding payment of a MSP reimbursement claim with threats of commencing collection actions before there is a resolution of an appeal or waiver request.
"IT IS FURTHER ORDERED that the Defendant's demand that attorneys withhold liability proceeds from clients pending payment of amounts claimed by the Defendant as MSP reimbursement exceeds her authority under the Medicare statute, and Defendant is enjoined from demanding that attorneys withhold liability proceeds from their clients pending payment of disputed MSP reimbursement claims.In reaching its decision to allow discovery, the Court held that the putative class, that is challenging the recovery methods of Medicare, is permitted to extend discovery beyond the limited administrative record action without the necessity of the exhaustion of administrative remedies since constitutional and due process were collateral to any individual claim.
The issues reviewed by the court were:
"1) whether Defendant [CMS] can require prepayment of an MSP recovery claim before the correct amount is determined through the administrative appeal procedures, and
2) whether Defendant [CMS] can make plaintiffs' attorneys financially responsible if they do not hold or immediately turn over to the Defendant [CMS] their clients' litigation proceeds.
These questions involve a due process analysis, which consists of a three part balancing test:
1) the private interest affected;
2) the risk of erroneous deprivation and probable value of additional safeguards, and
3) the government or public interest in current procedures. "
Haro v. Sebelius, (A. Ariz.) CV 09-134 TUC DCB
Thursday, February 17, 2011
Medicare Secondary Payment Interest Calculation Tool Updated
The Medicare Secondary Payer Recovery Contractor (MSPRC) has published an updated version of its Interest Calculation Tool.
- Interest Periods tab The Interest Periods tab gives you the ability to enter a specific demand date and calculate the exact day interest will be assessed each month thereafter for that demand.
- Demands before October 2004 tab Demands that were issued prior to October 1, 2004 are handled slightly differently. This tab allows you to perform appropriate interest calculations that are tailored to these specific demands.
- How Interest is Calculated tab Want to know how interest is calculated? This tab provides education on MSPRC's interest calculation process. This includes how the accrual of interest is calculated from day 1 of the demand letter date, the 60-day grace period to pay that amount, and how interest is assessed on the demand amount if the demand is not paid within the grace period. This tab also provides the actual formula for interest calculation to give you a better understanding of the process. Download the Excel based tool at: http://www.msprc.info/forms/Interest%20Calculation%20Tool%20(GHP%20&%20NGHP).xls
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Saturday, February 12, 2011
Published: 2011 Workers' Compensation Law Treatise
What's New
The newly enacted statutory changes to the New Jersey Workers’ Compensation Act and promulgated Rules permitting Emergent Medical Care Motions, new registration requirements for insurers, and new judicial enforcement powers of Judges of Compensation, including sanctions and contempt powers, are contained in this supplemental material. The judicial decision imposing direct liability against an insurance carrier for delay and/or denial of medical treatment is discussed.
An analysis of the newly adopted procedures for the reimbursement of conditional payments established by Medicare and the protocols to co-ordinate workers’ compensation claims with the Centers for Medicare and Medicaid Services is contained in this supplement. The materials also provide the authorizations required to obtain conditional payment information from the Coordinator of Benefits. Debt collection referral to the Department of the Treasury is also reviewed.
The new Community and Worker Right to Know material has been incorporated into this supplement. The current hazardous substance lists and the substances that have been deemed extremely dangerous are provided.
The supplement reviews new case law concerning electronic cancellation of coverage as well as the standard for claims to be considered casually related to the employment.
The judicial interpretation of the Exclusivity Doctrine is discussion in light of the dual capacity status of a household contact / bystander and also former employee. The evidential requirements in latent occupational claims is reviewed.
The mandatory reporting requirements of the SCHIP Extension Act of 2007 are described as well as the appeal procedure under the reimbursement provision of the Medicare Secondary Payer Act.
These pocket parts provide information concerning the requirements for medical monitoring in workers’ compensation claims. It discusses. the Asbestos Fund, which has been established for those entities where workers’ compensation coverage cannot be established. The newly designed forms that need to be utilized in filing for benefits are included. Also, the recently modified Motion for Temporary and Medical Benefits, including a form Certification, is provided and discussed.
The newly revised Judgments for Total and Permanent Disability are provided in this pocket part. The Judgments include new refinements in offsets for pensions and Social Security disability benefits. Reviewed also is the “intentional wrong exception” to the Exclusivity Bar which has been the subject of new workers’ compensation insurance policy language and regulation.
The recently promulgated administrative rules governing the disposition of Temporary Disability Benefits are discussed. The non-duplication of benefits provisions are reviewed including the multiple agency adjudication process. An expansion of benefits available to Federal public safety officers is reviewed in this supplement.
Collateral medical benefit issues are discussed in light of the recent Supreme Court decision concerning this matter. The pocket parts include a Motion to Join the Collateral Health Carrier and provide sample Certifications to be used in support of the application. New pleadings issued by the Division of Workers’ Compensation in the area of medical payment and reimbursement claims are provided and commented upon in these materials.
Additionally, these pocket parts provide information concerning the new Rules of the Division of Workers’ Compensation embodying electronic filing requirements and new procedures involving both formal and informal proceedings, motion practice, post judgment process, and judicial performance. The expanded Medicare secondary reporting requirements and the mandatory coordination of benefits are reviewed in this supplement. The recovery aspects of Medicare conditional payments as well as future medical provisions are updated and discussed. The new Child Support Lien distribution forms, computation worksheets and judgments are provided and explained in depth. The NJ Supreme’ Court ruling and the legislative enactments are discussed concerning same sex couples and the availability of workers’ compensation benefits.
This supplement reviews the newly promulgated Rules concerning the Uninsured Employers’ Fund and audio and video coverage of workers’ compensation proceedings. The horrific tragedy of September 11th, 2001 and the impact it has upon the Workers’ Compensation system is discussed. This supplement reviews the newly enacted Smallpox Emergency Protection Act as well as recent court decisions concerning acts of terrorism. The subsequent legislative changes enacted in response to potential terrorist threats are reviewed, including the Public Safety Officers’ Benefit Act as well as the liberalized legislative enactments involving rescue workers and medical personnel.
The far-reaching ramifications of the newly enacted healthcare reform legislation are reviewed. The new prototype occupational medical care program, encompassing potential occupational exposure claims, is presented in this supplement.
The impact of the newly promulgated Federal rules and regulations concerning medical record privacy and compliance with the Health Insurance Portability and Accountability Act (HIPPA) medical authorization requirements are reviewed in this supplement and model forms are furnished. The recently enacted statutory workers' compensation coverage options available to proprietors and partners are discussed. The supplement reviews the recent court decisions expanding the responsibility of the Second Injury Fund for pre-existing medical conditions in cases in which latent diseases become manifest during retirement. The statutory enactments concerning State Temporary Disability Benefits are reviewed. The recently amended Energy Employees Occupational Illness Compensation Act is explained in detail and forms are furnished and discussed.
The new administration and management of claims arising from insolvent workers’ compensation insurance is covered in this pocket part.
The recent Supreme Court decisions concerning the high judicial threshold for evaluation of scientific evidence are analyzed. The requirements for proof of scientific evidence in complex workers’ compensation cases are discussed including the admissibility of testimony from non-physicians experts. Furthermore, the evolving and expanding issues concerning medical monitoring are reviewed.
This pocket part also discusses recent changes in the application for counsel fees. The supplement includes the newly promulgated administrative directive embodying those changes.
To Order
An analysis of the newly adopted procedures for the reimbursement of conditional payments established by Medicare and the protocols to co-ordinate workers’ compensation claims with the Centers for Medicare and Medicaid Services is contained in this supplement. The materials also provide the authorizations required to obtain conditional payment information from the Coordinator of Benefits. Debt collection referral to the Department of the Treasury is also reviewed.
The new Community and Worker Right to Know material has been incorporated into this supplement. The current hazardous substance lists and the substances that have been deemed extremely dangerous are provided.
The supplement reviews new case law concerning electronic cancellation of coverage as well as the standard for claims to be considered casually related to the employment.
The judicial interpretation of the Exclusivity Doctrine is discussion in light of the dual capacity status of a household contact / bystander and also former employee. The evidential requirements in latent occupational claims is reviewed.
The mandatory reporting requirements of the SCHIP Extension Act of 2007 are described as well as the appeal procedure under the reimbursement provision of the Medicare Secondary Payer Act.
These pocket parts provide information concerning the requirements for medical monitoring in workers’ compensation claims. It discusses. the Asbestos Fund, which has been established for those entities where workers’ compensation coverage cannot be established. The newly designed forms that need to be utilized in filing for benefits are included. Also, the recently modified Motion for Temporary and Medical Benefits, including a form Certification, is provided and discussed.
The newly revised Judgments for Total and Permanent Disability are provided in this pocket part. The Judgments include new refinements in offsets for pensions and Social Security disability benefits. Reviewed also is the “intentional wrong exception” to the Exclusivity Bar which has been the subject of new workers’ compensation insurance policy language and regulation.
The recently promulgated administrative rules governing the disposition of Temporary Disability Benefits are discussed. The non-duplication of benefits provisions are reviewed including the multiple agency adjudication process. An expansion of benefits available to Federal public safety officers is reviewed in this supplement.
Collateral medical benefit issues are discussed in light of the recent Supreme Court decision concerning this matter. The pocket parts include a Motion to Join the Collateral Health Carrier and provide sample Certifications to be used in support of the application. New pleadings issued by the Division of Workers’ Compensation in the area of medical payment and reimbursement claims are provided and commented upon in these materials.
Additionally, these pocket parts provide information concerning the new Rules of the Division of Workers’ Compensation embodying electronic filing requirements and new procedures involving both formal and informal proceedings, motion practice, post judgment process, and judicial performance. The expanded Medicare secondary reporting requirements and the mandatory coordination of benefits are reviewed in this supplement. The recovery aspects of Medicare conditional payments as well as future medical provisions are updated and discussed. The new Child Support Lien distribution forms, computation worksheets and judgments are provided and explained in depth. The NJ Supreme’ Court ruling and the legislative enactments are discussed concerning same sex couples and the availability of workers’ compensation benefits.
This supplement reviews the newly promulgated Rules concerning the Uninsured Employers’ Fund and audio and video coverage of workers’ compensation proceedings. The horrific tragedy of September 11th, 2001 and the impact it has upon the Workers’ Compensation system is discussed. This supplement reviews the newly enacted Smallpox Emergency Protection Act as well as recent court decisions concerning acts of terrorism. The subsequent legislative changes enacted in response to potential terrorist threats are reviewed, including the Public Safety Officers’ Benefit Act as well as the liberalized legislative enactments involving rescue workers and medical personnel.
The far-reaching ramifications of the newly enacted healthcare reform legislation are reviewed. The new prototype occupational medical care program, encompassing potential occupational exposure claims, is presented in this supplement.
The impact of the newly promulgated Federal rules and regulations concerning medical record privacy and compliance with the Health Insurance Portability and Accountability Act (HIPPA) medical authorization requirements are reviewed in this supplement and model forms are furnished. The recently enacted statutory workers' compensation coverage options available to proprietors and partners are discussed. The supplement reviews the recent court decisions expanding the responsibility of the Second Injury Fund for pre-existing medical conditions in cases in which latent diseases become manifest during retirement. The statutory enactments concerning State Temporary Disability Benefits are reviewed. The recently amended Energy Employees Occupational Illness Compensation Act is explained in detail and forms are furnished and discussed.
The new administration and management of claims arising from insolvent workers’ compensation insurance is covered in this pocket part.
The recent Supreme Court decisions concerning the high judicial threshold for evaluation of scientific evidence are analyzed. The requirements for proof of scientific evidence in complex workers’ compensation cases are discussed including the admissibility of testimony from non-physicians experts. Furthermore, the evolving and expanding issues concerning medical monitoring are reviewed.
This pocket part also discusses recent changes in the application for counsel fees. The supplement includes the newly promulgated administrative directive embodying those changes.
To Order
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More Information
Table of Contents Supp. 2011
Index, Supp. 2011
Summary of Contents
Related articles
More Information
Table of Contents Supp. 2011
Index, Supp. 2011
Summary of Contents
Related articles
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