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Showing posts with label Medicaid. Show all posts
Showing posts with label Medicaid. Show all posts

Thursday, August 29, 2013

Claims Adjuster, TPA Could Face Criminal Charges for Worker Fatality



Today's post was shared by WCBlog and comes from www.propertycasualty360.com


The egregious ­mismanagement
of a California workers’ compensation
claim is being blamed for an
injured worker’s severe infection
and resultant death.

The ongoing case is drawing ire from various associations, including the California Applicants’ Attorneys Association (CAAA), which is lobbying that criminal charges be filed against Sedgwick Claims Management Services, the third-party administrator involved in the claim, as well as one of its adjusters.

The initial workers’ compensation claim originated when Charles Romano injured his shoulder and cervical spine on Dec. 20, 2003 while stocking shelves at a Ralph’s grocery store (part of The Kroger Co.) in Camarillo, Calif. After undergoing surgery for the resultant injuries on August 29, 2005, Romano contracted methicillin-resistant straphylococcus aureus (MRSA), which not only caused renal and pulmonary failure but also paralysis below the shoulders (from C8 down).

Romano later sought treatment for the serious infection at the Ventura County Medical Center, where he had no choice but to use Medi-Cal—the state’s version of Medicaid—because Sedgwick refused to authorize treatment. In fact, Medi-Cal paid for Romano’s medical bills dating from November 2005 through February 2007, ultimately picking up a tab for $300,000.

Fatal Consequences
On October 25, 2006, a workers’ compensation judge issued an amended findings and award,ruling that the MRSA infection was a...
[Click here to see the rest of this post]

Friday, June 7, 2013

Workers are too scared in the US to file claims

A recent research report indicated that workers fail to report occupational illness and accidents for fear of retribution by their employers. Most state laws prohibition retaliation by employers, but it is very difficult to enforce that aspect of workers' compensation statutes.

 2013 May 13. doi: 10.1111/1475-6773.12066. [Epub ahead of print]

The Proportion of Work-Related Emergency Department Visits Not Expected to Be Paid by Workers' Compensation: Implications for Occupational Health Surveillance, Research, Policy, and Health Equity.

Source

National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, OH.

Abstract

OBJECTIVE:

To examine trends in the proportion of work-related emergency department visits not expected to be paid by workers' compensation during 2003-2006, and to identify demographic and clinical correlates of such visits.

DATA SOURCE:

A total of 3,881 work-related emergency department visit records drawn from the 2003-2006 National Hospital Ambulatory Medical Care Surveys.

STUDY DESIGN:

Secondary, cross-sectional analyses of work-related emergency department visit data were performed. Odds ratios and 95 percent confidence intervals were modeled using logistic regression.

PRINCIPAL FINDINGS:

A substantial and increasing proportion of work-related emergency department visits in the United States were not expected to be paid by workers' compensation. Private insurance, Medicaid, Medicare, and workers themselves were expected to pay for 40 percent of the work-related emergency department visits with this percentage increasing annually. Work-related visits by blacks, in the South, to for-profit hospitals and for work-related illnesses were all more likely not to be paid by workers' compensation.

CONCLUSIONS:

Emergency department-based surveillance and research that determine work-relatedness on the basis of expected payment by workers' compensation systematically underestimate the occurrence of occupational illness and injury. This has important methodological and policy implications.
© Health Research and Educational Trust.
PMID:
 
23662682
 
[PubMed - as supplied by publisher]

Friday, May 24, 2013

Doctors and hospitals’ use of health IT more than doubles since 2012


More than half of America’s doctors have adopted electronic health records
HHS Secretary Kathleen Sebelius today announced that more than half of all doctors and other eligible providers have received Medicare or Medicaid incentive payments for adopting or meaningfully using electronic health records (EHRs).
HHS has met and exceeded its goal for 50 percent of doctor offices and 80 percent of eligible hospitals to have EHRs by the end of 2013.
Adoption of Electronic Health Records by Physicians and Other Providers - Click for larger graphSince the Obama administration started encouraging providers to adopt EHRs, usage has increased dramatically. According to the Centers for Disease Control and Prevention survey in 2012, the percent of physicians using an advanced EHR system was just 17 percent in 2008. Today, more than 50 percent of eligible professionals (mostly physicians) have demonstrated meaningful use and received an incentive payment. For hospitals, just nine percent had adopted EHRs in 2008, but today, more than 80 percent have demonstrated meaningful use of EHRs.
“We have reached a tipping point in adoption of electronic health records,” said Secretary Sebelius. “More than half of eligible professionals and 80 percent of eligible hospitals have adopted these systems, which are critical to modernizing our health care system. Health IT helps providers better coordinate care, which can improve patients’ health and save money at the same time.”
Adoption of Electronic Health Records by Eligible Hospitals - Click for larger graphThe Obama administration has encouraged the adoption of health IT starting with the passage of the Recovery Act in 2009 because it is an integral element of health care quality and efficiency improvements. Doctors, hospitals, and other eligible providers that adopt and meaningfully use certified electronic health records receive incentive payments through the Medicare and Medicaid EHR Incentive Programs. Part of the Recovery Act, these programs began in 2011 and are administered by the Centers for Medicare & Medicaid Services and the Office of the National Coordinator of Health Information Technology.
Adoption of EHRs is also critical to the broader health care improvement efforts that have started as a result of the Affordable Care Act. These efforts – improving care coordination, reducing duplicative tests and procedures, and rewarding hospitals for keeping patients healthier – all made possible by widespread use of EHRs. Health IT systems give doctors, hospitals, and other providers the ability to better coordinate care and reduce errors and readmissions that can cost more money and leave patients less healthy. In turn, efforts to improve care coordination and efficiency create further incentive for providers to adopt health IT.
As of the end of April 2013:
  • More than 291,000 eligible professionals and over 3,800 eligible hospitals have received incentive payments from the Medicare and Medicaid EHR Incentive Programs.
  • Approximately 80 percent of all eligible hospitals and critical access hospitals in the U.S. have received an incentive payment for adopting, implementing, upgrading, or meaningfully using an EHR.
  • More than half of physicians and other eligible professionals in the U.S. have received an incentive payment for adopting, implementing, upgrading, or meaningfully using an EHR.
For more information about the Administration’s efforts to promote implementation, adoption and meaningful use of EHRs and health IT systems, please visit: http://www.cms.gov/EHRIncentivePrograms and http://www.healthit.gov.
......
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.  Click here now to submit a case inquiry.
Read more about "Medical Records" and workers' compensation
Aug 23, 2011
The lack privacy of medical records in workers' compensation claims has perpetually been a huge concern for workers since Congress ignored requests to protect their dissemination. A recent disclosure in California that the ...
May 16, 2013
The lack privacy of medical records in workers' compensation claims has perpetually been a huge concern for workers since Congress ignored requests to protect their dissemination. A recent disclosure in California that the .
Oct 04, 2011
The Need to Incorporate Occupational Histories Into Electronic Medical Records. Each year in the United States, more than 4,000 occupational fatalities and more than 3 million occupational injuries occur along with more ...
Mar 11, 2013
They can pour over your medical records, pre- and post-injury, looking for any piece of evidence to deny your claim. They can send your file to lawyers who review medical records and recorded statements to potentially attack ...

Saturday, December 1, 2012

Hospital Controlled Physician Access and Workers' Compensation

As hospital consolidation of physician practices by acquisition continues, the question of the impact on control of the cost workers' compensation medical delivery remains uncertain.

Hospitals, supported by private equity, are now buying physician practices at a greater pace than ever before making choices for physician care more limited and at a higher cost. The New York Times reports that physicians who sell their practices hospitals find that they are under pressure to meet economic challenges of hospital targeted fees and are restricted in the referral of patients.

"....the consolidation of health care may be coming at a hefty price. By one estimate, under its current reimbursement system, Medicare is paying in excess of a billion dollars a year more for the same services because hospitals, citing higher overall costs, can charge more when the doctors work for them. Laser eye surgery, for example, can cost $738 when performed by a hospital-employed doctor, compared with $389 when done by an unaffiliated doctor, according to national estimates by the independent Congressional panel that oversees Medicare. An echocardiogram can cost about twice as much in a hospital: $319, versus $143 in a doctor’s office."

Read the complete article:  A Hospital War Reflects a Bind for Doctors in the U.S.

Read more about "medical Costs" and workers' compensation

Nov 01, 2012
Planned changes by Mitt Romney to Medicare and Medicaid will have a dire effect on the regulations of the future cost of workers' compensation medical treatment. Proposed changes to the Federal program will indirectly ...
Nov 22, 2012
A report issued by NCCI concludes that medical costs in Workers' Compensation were higher in some instances than in Group Health Plans. The main findings were: For comparable injuries, when WC pays higher prices than ...
Nov 15, 2012
“While the average medical cost for a workers compensation claim is approximately $6,000, the medical cost of an individual claim can be a few hundred dollars or millions of dollars. In 2010, an NCCI study found that claims ...
Nov 29, 2012
The perpetual cost generator that continues to rage out of control in workers' compensation programs is the medical component. Medical costs are crashing the system to failure across the country, with no hope in sight for ...



Thursday, November 1, 2012

Workers' Compensation Jeopardy: Romney and Medical Costs

Mitt Romney
Planned changes by Mitt Romney to Medicare and Medicaid will have a dire effect on the regulations of the future cost of workers’ compensation medical treatment. Proposed changes to the Federal program will indirectly impact the patchwork of workers' compensation programs by removing federally mandated fee regulation embraced under Obamacare.
Directly or indirectly, most workers' compensation programs have medical treatment and pharmaceutical pricing costs that are geared to Federal payment schedules regulated by the Medicare and Medicaid systems. Additionally, the Medicare Secondary Payer Act mandates reimbursement to the Federal, and State administered, and in many instances the Federal costs are less than the customary payments under workers’ compensation systems. Therefore the Federal programs, even if conditionally paid, result in lower payments eventually by employers and workers' compensattion insurance companies who in term are required to reimburse the Federal agency.
Additionally, the elimination of the Federal controls, that put a lid on the cost of benefits, would adversely affect the workers' compensation programs by creating havoc by eliminating the certainty of reduced costs, especially where future costs are concerned, ie. catastrophic care scenarios and latent diseases, ie. asbestosis.
Paul Krugman (NYTimes) points out, “But one thing is clear: If he [Romney] wins, Medicaid — which now covers more than 50 million Americans, and which President Obama would expand further as part of his health reform — will face savage cuts. Estimates suggest that a Romney victory would deny health insurance to about 45 million people who would have coverage if he lost, with two-thirds of that difference due to the assault on Medicaid.”
The Romney agenda to dismantle the present medical benefit program will only further jeopardize the economic stability of the nation’s workers’ compensation system. 
....
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). 
Read More About Romney and Medical Care
Oct 07, 2012
The Chemical Lobby, and those who advocate of their behalf for less regulation, including presidential candidate Mitt Romney are now advocating for less regulation and the elimination of the semi-annual publication The ...
Dec 26, 2011
"Romney and his aides have designed his rhetoric to define pretty much all spending on entitlements, including provisions for the injured, unemployed, sick, disabled or elderly as benefits to the poor who, Romney implies, are ...
Feb 01, 2012
While both leading Republican candidates are throwing darts at each other on many points, the basic philosophy of both Mitt Romney and Newt Gingrich is to extinguish the so-called "entitlement society." They claim Barack ...
Sep 04, 2012
Mr. Eastwood is a former businessman and, according to Republican nominee Mitt Romney, that is an essential qualification for President. So maybe that's why Eastwood was given such a prominent role before Romney ...

Wednesday, April 11, 2012

GAO Releases Report on Medicare Secondary Recovery Procedures

The US Government Accounting Office has released a report concerning the efficiency of the Medicare Secondary Recovery process.


Identified Issues:

  • Contractor performance. Challenges related to the timeliness of the MSPRC and WCRC were identified, including significant increases in the time required to complete important tasks. CMS reported taking steps to address the challenges with each of these contractors’ performance.
  • Demand and recovery issues. Challenges were identified related to the timing of demand amounts, the cost-effectiveness of recovery efforts, and the amounts of Medicare demands from liability settlements. CMS reported taking steps to address some, but not all, of these challenges.
  • Mandatory reporting. Key challenges were identified with certain aspects of mandatory reporting: determining whether individuals are Medicare beneficiaries, supplying diagnostic codes related to individuals’ injuries, and reporting all liability settlement amounts. CMS reported taking steps to address some, but not all, of these challenges.
  • CMS guidance and communication. Key challenges were identified related to CMS guidance and communication about the MSP process, guidance on Medicare set-aside arrangements, and beneficiary rights and responsibilities. CMS has taken few steps to address these challenges.

"To improve the MSP program, GAO is making recommendations to improve the cost-effectiveness of recovery, decrease the reporting burden for NGHPs, and improve communications with NGHP stakeholders. CMS agreed with these recommendations."

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

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. 


Deborah Taylor, Chief Financial Officer and Director, Office of Financial Management Centers for Medicare and Medicaid Services, stated, "Any restrictions on existing MSP rights or recovery processes would adversely affect savings that would otherwise accrue to the Medicare Trust Funds through MSP recovery activities, as well as the $1 billion per year in cost-avoided savings that CMS is able to track. Proposals that would impose mandatory process changes may affect Medicare’s status as a secondary payer or its priority right of recovery, as well as CMS’ ability to prioritize its own workload. These changes may also have the unintended effect of undercutting the underlying intent of the statute, increasing costs, and reducing existing savings. " 

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."


Related Resources


Friday, March 18, 2011

Industry Coalition Wants to Cut CMS Conditional Payments

A group of about 50 employers, insurance carriers and vendors have formed a coalition to endorse legislation  (H.R.1063) introduced this week that would ease reporting requirements and reimbursement procedures of the Centers for Medicare and Medicaid (CMS). The organization, the Medicare Advocacy Recovery Group [MARC],  contends that the proposed legislation will:
  • "Empowering Medicare to provide settling parties with the amount of their MSP repayment obligation during the settlement process, will allow taxpayers to settle quicker, and repay the Medicare Trust Fund faster.
  • "MSP Reform will provide a more affordable and less intrusive MSP system that protects beneficiaries and the Medicare Trust Fund, but does not waste limited judicial and other resources or needlessly confuse parties trying to settle a claim resulting from an injury to a beneficiary. 
  • "MSP Reform will also eliminate the required use of Social Security Numbers (SSNs) and Health Insurance Claim Numbers (HICNs) in the reporting process, create a basic right of appeal for all parties to resolve a CMS MSP determination, clarify the statute of limitations, and require the CMS Actuary to determine a threshold below which the recoveries are so small it makes no sense to apply the complex MSP laws. 
Theoretically it sounds like the change would create a more efficient system to establish: time limits for claim reimbursement; a statute of limitations for liability (3 years); an avenue for redress directly to the judicial system; and a threshold amount for reimbursement. However, the proposal would actually defeat the basic philosophy of the workers' compensation act. 

The convoluted logic of the employer/insurance group just makes no sense. It is like saying that I didn't bother buying enough postage on a timely basis so I will just mail my letter at half-price. The universal legislative intent of workers' compensation act mandates that the employer is responsible for medical care of its injured workers. The insurance industry has tried other gimmicks  before to continue its long history of cost shifting, and those have rightly failed as Congress wouldn't buy into them.

While employers and insurance carriers delay and deny compensation benefits, shifting the cost to the taxpayers through depletion of the Medicare system, is both offensive and repugnant. If the coalition wants to ride the carousel of "it's not how long, but how much," in doling out benefits, then they should not blame CMS for delays and penalties, caused by the coalition's own failure to report on a timely basis in the first place.

Related articles

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
Related articles

Thursday, December 2, 2010

CMS Issues Series of Mandatory Reporting Alerts

Centers for Medicare and Medicaid Services (Me...Image via Wikipedia
The Centers for Medicare and Medicaid Services (CMS) has recently issued a series of Alerts for Implementation of Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (See 42 U.S.C. 1395y(b)(7) & (8)).


One of Alerts defines the Date of Incidence (DOI) for a cumulative injury which is the earlier of:

• The date that treatment for any manifestation of the cumulative injury began when such treatment preceded formal diagnosis; or
• The first date that formal diagnosis was made by any medical practitioner.



MMSEA 111 - Alert - November 18, 2010 - ALERT: Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation - Special Default ICD-9 Code for Responsible Reporting Entities (RREs) [PDF 69.45KB] 

MMSEA 111 - Alert - November 18, 2010 - ALERT:  TIN Reference File Address Validation Information for Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation Responsible Reporting Entities (RREs) [PDF 58.76KB] 

MMSEA 111 - Alert- November 9, 2010 - I. Revised Implementation Timeline for TPOC Liability Insurance (Including Self-Insurance) Settlements, Judgments, Awards or Other Payments and II. Extension of Current Dollar Thresholds for Liability Insurance (Including Self-Insurance)  and Workers' Compensation [PDF 46.95KB] 

MMSEA 111 - Revised Alert - November 5, 2010 - Direct Data Entry (DDE) Registration Information for Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers' Compensation [PDF 49.17KB] 

MMSEA 111 – Revised Alert - November 5, 2010 - New Direct Data Entry (DDE) Option for Liability Insurance (Including Self-Insurance), No-Fault Insurance and Workers' Compensation [PDF 65.37KB] 

MMSEA111 - Alert - October 14, 2010 - Alert For Liability (Including Self-Insurance), No-Fault Insurance and Workers' Compensation - Reporting Timeframe [PDF 44.34KB] 

MMSEA111 - Alert - October 14, 2010 - Alert For Liability (Including Self-Insurance), No-Fault Insurance and Workers' Compensation - DOI For Cumulative Injury [PDF 40.89KB] 


New information concerning ICD Provider & Diagnostic Codes has also been posted to the CMS website:
Version 28 Full and Abbreviated Code Titles - Effective October 1, 2010 [ZIP 922KB] 


Conversion information to the proposed (NEW) ICD-10 Codes is also posted.