A Federal Court in California has prohibited the Center for Medicare and Medicaid Services (CMS) from seeking reimbursement of conditional payments when the medical codes for the conditions are unrelated or not related even if the primary code was for a work-related medical condition. The court made the following ruling in a motion for partial summary judgment in a declaratory judgment action.
Showing posts with label Conditional Payments. Show all posts
Showing posts with label Conditional Payments. Show all posts
Saturday, May 6, 2017
Friday, January 13, 2017
Medicare Advantage Organization Allowed to Sue Law Firm and Lawyer Over Conditional Payments
A Federal Court has ruled that a Medicare Advantage Organization (MAO) is permitted under the law to sue a law firm and a lawyer for the failure to reimburse conditional medical expenses arising out of an accident.
US District Court Judge, Henry E. Hudson, ruled that the Medicare Secondary Payer statute created a private cause of action to pursue recovery for conditional payments that it made on the beneficiary's behalf for medical expenses resulting from an automobile accident.
"Although not binding precedent, this Court finds persuasive the Third Circuit's determination that a MAO may pursue recovery pursuant to the private right of action in § 1395y(b)(3)(A). Section 1395y(b)(2)(A)'s plain language establishes a private right of action to recover double damages where a primary plan fails to pay. Absent from the plain language of the statute is any restriction upon who may utilize that private right of action."
Humana Insurance Co. v Paris Blank LLP, 197 F. Supp. 3d 676 (E.D. Virginia 2016)
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.
Monday, October 5, 2015
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.
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.
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| 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."
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."
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
Click below to read the post on LinkedIn:
New Process for Primary Payers Resolving Medicare Conditional Payments Begins Today
Tuesday, August 27, 2013
No Shopping Zone: Medicare Is Not Part Of New Insurance Marketplaces
Medicare is integrated with many aspects of state workers' compensation programs. From medical fee setting to reimbursement for conditional payments under the Medicare Secondary Payer Act. Today's post was shared by Kaiser Health News and comes from www.kaiserhealthnews.org
[Click here to see the rest of this post]
While the Obama administration is stepping up efforts encouraging uninsured Americans to enroll in health coverage from the new online insurance marketplaces, officials are planning a campaign to convince millions of seniors to please stay away – don't call and don't sign up.
"We want to reassure Medicare beneficiaries that they are already covered, their benefits are not changing and the marketplace doesn't require them to do anything," said Michele Patrick, Medicare's deputy director for communications. To reinforce the message, she said the 2014 "Medicare & You" handbook – the 100-plus-page guide that will be sent to 52 million Medicare beneficiaries next month -- contains a prominent- notice: "The Health Insurance Marketplace, a key part of the Affordable Care Act, will take effect in 2014. It's a new way for individuals, families, and employees of small businesses to get health insurance. Medicare isn't part of the Marketplace." Still, it can be easy to get the wrong impression. "You hear programs on the radio about the health care law and they never talk about seniors and what we are supposed to do," said Barbara Bonner, 72, of Reston, Va. "Do we have to go sign up like they're saying everyone else has to? Does the new law apply to us seniors at all and if so, how?" Enrollment in health plans offered on the marketplaces, also called exchanges, begins Oct. 1 and runs for six months. Meanwhile, the two-month sign-up period for private health plans for... |
Related articles
- The 10 Highest Medical Cost Jurisdictions for Medicare (workers-compensation.blogspot.com)
- Colorado Exchange Releases Health Insurance Rates (workers-compensation.blogspot.com)
- US Supreme Court Asked to Review MSP Preemption Issue (workers-compensation.blogspot.com)
- Medicare To Punish 2,225 Hospitals For Excess Readmissions (workers-compensation.blogspot.com)
- Pa., N.J. Insurers Gearing Up For Obamacare Business (workers-compensation.blogspot.com)
- It's Complicated: Obamacare's Choices for People with Disabilities (workers-compensation.blogspot.com)
Friday, January 11, 2013
Obama signs MSP Medicare bill
"The legislation changes the way Medicare collects money from people whose negligence caused a patient to incur medical bills. Murphy said the new law will streamline an outdated process, making it easier to close cases and bring money into the Medicare program."
Read more: http://thehill.com/blogs/healthwatch/medicare/276621-obama-signs-medicare-bill#ixzz2HehBHham
Questions remain on the practicalities of implementation as regulations need to be promulgated.
The NEW law will be discussed at the Hot Topics in Workers' Compensation Law 2013 Seminar (NJ ICLE Jn 29, 2013)
Read more: http://thehill.com/blogs/healthwatch/medicare/276621-obama-signs-medicare-bill#ixzz2HehBHham
Questions remain on the practicalities of implementation as regulations need to be promulgated.
The NEW law will be discussed at the Hot Topics in Workers' Compensation Law 2013 Seminar (NJ ICLE Jn 29, 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 ...
Friday, December 28, 2012
Legislation Goes to President Obama on CMS Condition Payment Procedures
Under the proposed legislation time periods for reporting by parties to CMS (The Center for Medeicare and Medicaid Services) are eased, penalities for insurance carriers are reduced, and a 3 year statute of limitations is established.
The legislation was merged into another pending bill for medical services and was rushed to a favorable vote in both the House and Senate in the last moments before Christmas.
What remains to be determined are the regulations that will be established to implement the legislation. In the past, such regulations usually set boundries for such legislation and may in the end further complicate and even prolong resolution of the issues.
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 ...
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 ...
Dec 23, 2008
A formal process exits to obtain a waiver of an Overpayment Recovery request from The Center for Medicare and Medicaid Services [CMS]. If SSA advises you or your client that it has made an overpayment, ie. Medicare ...
Thursday, July 12, 2012
NJ Division of Workers Compensation Modifying CMS Process Policy
The NJ Division of Workers' Compensation is modifying its policy concerning Conditional Payments and Medicare Set-Aside issues. The Division has announced flexibility in settlement formats to allow the utilization of alternate language when approving dispositions.
Click here to read the complete Memorandum of July 11, 2012.
Click here to read the complete Memorandum of July 11, 2012.
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