Showing posts with label MSP. Show all posts
Showing posts with label MSP. Show all posts
Friday, September 27, 2024
Chevron's Fall: Medicare Set-Asides Face Legal Shake-Up
The recent U.S. Supreme Court decision in Loper Bright Enterprises v. Raimondo (2024), which overturned the Chevron doctrine established in Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., is likely to have significant impacts on how the Centers for Medicare & Medicaid Services (CMS) operates regarding the Medicare Secondary Payer (MSP) Act, including conditional payments and Medicare Set-Aside (MSA) agreements.
Tuesday, September 13, 2022
CMS Expands Options for Defense Submissions for CRCP
Commercial Repayment Center Portal (CRCP) Defense Submission Frequently Asked Questions
Recently a change was made to the portal that allows CRCP users to associate defenses to the individual claims included in recovery demands. This more granular response to demands, where Group Health Plans (GHPs) specify the basis of defense submissions, allows for more efficient and accurate reviews of the submitted defenses. What follows are answers to frequently asked questions received by the Commercial Repayment Center (CRC) in regard to this change. Additional details on the functionality are available in Version 3.2 of the CRCP User Guide, which is available in the “Reference Materials” section of the CRCP.
Sunday, February 7, 2021
Investigative Report Raises Issues
The tension between public pension systems and workers' compensation programs was highlighted in a recent investigative report by the NJ State Comptroller. The report raises additional critical issues common to other state and national collateral social insurance programs challenged by current fiscal limitations.
Friday, October 11, 2019
CMS Cannot Seek Reimbursement from Insurance Guarantee Fund
The US 9th Circuit Court of Appeals has ruled that The Centers for Medicare and Medicaid [CMS] cannot not seek reimbursement from from the California Insurance Guarantee Association for workers' compensation payments.
Monday, September 10, 2018
CMS has scheduled another webinar for Wed., Sept 19, 2018
Commercial Repayment Center Portal (CRCP) Overview Webinar Wednesday, September 19 th, 2018 CMS will be hosting a webinar to present an overview of the Commercial Repayment Center Portal (CRCP) functions.
Monday, April 30, 2018
NJ Mandates Reporting of Medicare Conditional Payments
The NJ Division of Workers’ Compensation has now mandated the reporting of pending workers’ compensation claims possibly eligible for reimbursement of conditional medical payments to the US Centers for Medicare and Medicare Services (CMS) as a condition precedent to the settlement of a pending claim for benefits. The directive was outlined in a memorandum issued by Russell Wojtenko, Jr., Director and Chief Judge of Compensation on April 18, 2018.
Saturday, June 17, 2017
Governor of Nevada Vetoes Single-Payer Legislation
Nevada Governor Brian Sandoval has vetoed legislation that would have established a single-payer Assembly Bill 374 would have expanded a Medicare-type health care insurance plan. coverage to provide health care coverage to all Nevada residents.
Saturday, May 6, 2017
CMS Prohibited From Collecting for Unrelated Conditions
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.
Sunday, February 26, 2017
The limits on a total permanent disability award
The New Jersey Supreme Court recently heard oral argument concerning the mathematical limits of a workers’ compensation total disability case. At the heart of the case is the issue of whether an injured worker could have an increase in a pre-existing permanent partial disability [PPT] claim, that existed prior to the last compensable injury which was to another part of the body. The last compensable claim rendered the worker totally and permanently disabled.
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, October 7, 2016
US Department of Labor Urges Major Changes in the Nation's Workers' Compensation System
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
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.
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
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)
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.
Saturday, June 28, 2014
The Complexity of Medicare
While holding the for CMS (The Centers for Medicare and Medicaid Services) the complexity of the reimbursement of the Medicare Secondary Payer Act was recognized by a Federal Court:
"In re Avandia Mktg., 685 F.3d 353, 365 (3d Cir.2012); The Fourth Circuit has described the Medicare statute as “among the most completely impenetrable texts within human experience.” Rehab. Ass'n v. Kozlowski, 42 F.3d 1444, 1450 (4th Cir.1994). Other courts of appeal, including the District of Columbia Circuit, have echoed this assessment. See Abraham Lincoln Mem. Hosp. v. Sebelius, 698 F.3d 536, 540–41 (7th east Hosp. Corp. v. Sebelius, 657 F.3d 1, 13 (D.C. Cir.2011); Alhambra Hosp. v. Thompson, 259 F.3d 1071, 1076 (9th Cir.2001). For a more literary-flavored spin, consider Judge Lamberth's recent characterization of the statute as akin to “a law written by James Joyce and edited by E.E. Cummings.” Catholic Health Initiatives–Iowa, Corp. v. Sebelius, 841 F.Supp.2d 270, 271 (D.D.C.2012), rev'd, 718 F.3d 914 (D.C. Cir.2013).
Allina Health System v. Kathleen Sebelius, 982 F.Supp.2d 1 (DCT DC 2013)
"In re Avandia Mktg., 685 F.3d 353, 365 (3d Cir.2012); The Fourth Circuit has described the Medicare statute as “among the most completely impenetrable texts within human experience.” Rehab. Ass'n v. Kozlowski, 42 F.3d 1444, 1450 (4th Cir.1994). Other courts of appeal, including the District of Columbia Circuit, have echoed this assessment. See Abraham Lincoln Mem. Hosp. v. Sebelius, 698 F.3d 536, 540–41 (7th east Hosp. Corp. v. Sebelius, 657 F.3d 1, 13 (D.C. Cir.2011); Alhambra Hosp. v. Thompson, 259 F.3d 1071, 1076 (9th Cir.2001). For a more literary-flavored spin, consider Judge Lamberth's recent characterization of the statute as akin to “a law written by James Joyce and edited by E.E. Cummings.” Catholic Health Initiatives–Iowa, Corp. v. Sebelius, 841 F.Supp.2d 270, 271 (D.D.C.2012), rev'd, 718 F.3d 914 (D.C. Cir.2013).
Allina Health System v. Kathleen Sebelius, 982 F.Supp.2d 1 (DCT DC 2013)
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:
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 ...
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 ...
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 ...
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 ...
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]
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
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