The 11th Circuit Court of Appeals decided that a four-year statute of limitation applies to private actions pursued under the Medicare Secondary Payer Act [MSPA].
Showing posts with label Medicare Secondary Payer Act. Show all posts
Showing posts with label Medicare Secondary Payer Act. Show all posts
Thursday, August 11, 2022
Wednesday, June 20, 2018
Penalty Denied in MSP Private Cause of Action Claim for Delay in Reimbursement
While the personal representative of an estate had standing to bring a lawsuit against a medical provider for recoupment of money under the Medicare Secondary Payer Act [MSP], it was unable to seek double damages for delay in reimbursement of the money paid.
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.
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"Although not binding precedent, this Court finds persuasive the Third Circuit's determination that a MAO may pursue recovery pursuant to the private right of action in § 1395y(b)(3)(A).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)
Tuesday, May 17, 2016
CMS Publishes Final Rule for MSP Conditional Payments Via Web Portal
This final rule, effective June 16, 2016, specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act).
Thursday, September 5, 2013
9th Circuit Vacates MSP Injunction Against CMS for Medicare Reimbursement
The 9th Circuit Court of Appeals has vacated a Federal District Court Order enjoying CMS from seeking reimbursement for Medicare Conditional Payments under the Medicare Secondary Payer Act (MSP).
The Court held that it lacked jurisdiction:
****
Read prior posting about this case:
The Court held that it lacked jurisdiction:
"... we conclude that the***
beneficiaries' claim was not adequately presented to the
agency at the administrative level and therefore the district
court lacked subject matter jurisdiction pursuant to 42 U.S.C.§ 405(g) .
" Federal question jurisdiction does not extend to most
claims arising under the Medicare Act. The Medicare Act
incorporates 42 U.S .C. § 405(h) , which provides:
No findings of fact or decision of the
[Secretary] ... shall be reviewed by
any person, tribunal, or governmental
agency except as herein provided.
No action against the United States,
the [Secretary] ..., or any officer or
employee thereof shall be brought
under section 1331 ... of title 28 torecover on any claim arising under this
subchapter.
42 U.S.C. § 405(h) ; 42 U.S.C. § 1395ii .
****
"We decline to adopt the extraordinarily broad reading of***
Eldridge that the beneficiaries invite. We conclude that the
named plaintiffs' reimbursement disputes did not provide an
opportunity for the Secretary to consider the claim that her
interpretation of the secondary payer provisions exceeded
her authority. Their requests for redetermination of their
respective amounts of reimbursement did not constitute
presentment of their policy challenge.
" We conclude that the beneficiaries' claim wasHaro v Sebelius, ___F.3d____, No. 11-16606, 2013 WL 4734032, Decided Sept.4, 2013.
not presented to the agency. Because presentment is a
jurisdictional requirement under § 405(g) , the district court
lacked subject matter jurisdiction over the beneficiaries'
claim.
Read prior posting about this case:
May 18, 2011
Haro v. Sebelius, 2010 WL 1452942 (A. Ariz.) CV 09-134 TUC DCB, Decided April 12, 2010.The plaintiffs were permitted discovery beyond the administrative record. The class action is challenging the recovery procedures of ...
May 25, 2011
The MSPRC is still working cases, and the RAR and Demand letters will be mailed out once appropriate revisions have been made." This follows a recent US District Court ruling enjoining CMS's collection procedures. Haro v.
….
Jon L. Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). For over 4 decades the Law Offices of Jon L Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.
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... |
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Thursday, August 22, 2013
US Supreme Court Asked to Review MSP Preemption Issue
The US Supreme Court has been asked to review a claim on behalf of an injured worker who asserts that the Medicare Secondary Payer Act did not preempt State law (i.e.. Texas) that required a Workers' Compensation claimant to obtain preauthorization from relevant insurance carriers before incurring certain medical expenses. The Fifth Circuit Court of Appeals held that Medicare's conditional payment for a workers surgeries did not render the state law mandate for preauthorization requirements "moot."
A Writ of Certiorari was filed with the US Supreme Court on Aug. 8, 2012 and a response is due September 11, 2013
Guadalupe Caldera v. Insurance Company of the State of Pennsylvania, US Supreme Court Docket No. 12-40192. Case below, 716 F 3d 861, Docket No, 12-40192, 5th Cir Ct Appeals, Decided May 14, 2013.
….
Jon L.Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). For over 4 decades the Law Offices of Jon L Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.
Monday, June 17, 2013
Proposed Medicare Payment Reductions Will Impact Workers' Compensation Costs
A government Medicare advisory panel reported on Friday that sweeping changes should be implemented to reduce increasing medical costs, including higher costs associated with hospital purchased physician practices. The impact of those proposed adjustments will significantly impact the national workers' compensation systems because of both direct and indirect links between the two programs, including medical fee schedules, and Medicare Secondary Payment reimbursements.
The Medicare Payment Advisory Commission (MedPAC) releases its June 2013 Report to the Congress:
Medicare and the Health Care Delivery System.
According to Commission Chair Glenn Hackbarth, “This report can inform a dialogue about future
directions for the Medicare program, as well as about technical refinements to existing Medicare
payment policy. Whether broad or narrow, the Commission’s work aims to balance the interests of
Medicare beneficiaries, health care providers, and tax payers.”
Redesigning the Medicare benefit. In the report, the Commission continues its discussion of
possible ways to redesign the Medicare benefit by focusing on the concept we refer to as competitively
determined plan contributions (CPC). Under CPC, Medicare beneficiaries could receive care through
either a private plan or traditional fee-for-service (FFS), but the premium paid by the beneficiary might
vary depending on the coverage option they choose. How much the federal government pays for a
beneficiary’s care would be determined through a competitive process comparing the costs of available
options for coverage. The report identifies key issues to be addressed if the Congress wishes to pursue a
policy option like CPC. These include how benefits could be standardized for comparability, how to
calculate the Medicare contribution, the role FFS, and the structure of subsidies for low-income
beneficiaries.
Reducing Medicare payment differences across sites of care. Medicare’s payment rates often
vary for similar services provided to similar patients, simply because they are provided in different sites of
care. For example, Medicare pays 141 percent more for one type of echocardiogram when done in a
hospital outpatient department than when it is done in a freestanding physician’s office. If Medicare pays a
higher rate for a service in one setting over another, program spending increases and beneficiaries pay
more in cost sharing without a corresponding increase in quality of care.
The Commission previously recommended reducing the rate Medicare pays for basic office visits from the
payment rate in the outpatient setting to the physician office rate. Using similar criteria, this report identifies
additional services that may be eligible for equalizing or narrowing payment differences across settings.
Bundling post-acute care services. Each year, about one-quarter of Medicare beneficiaries receive
care following a hospitalization from a post-acute care provider, such as a skilled nursing facility, home
health agency, or inpatient rehabilitation facility. However, nationwide the use of these services varies
widely, for reasons not explained by differences in beneficiaries’ health status. Under traditional
Medicare, the program pays widely varying rates for different settings and—characteristic of FFS—pays
based on the volume of care provided, without regard to quality or resource use.
Medicare has begun to explore the possibility of bundling services as a way to encourage providers to
coordinate and furnish needed care more efficiently. In this report, the Commission explores the
implications for quality and program spending for different design features of the bundles, such as the
services included, the length of time covered by the bundle, and the method of payment.
Reducing hospital readmissions. In 2008, the Commission recommended a hospital readmissions
reduction program to improve patient experience and reduce Medicare spending. In 2012, Medicare
began such a program, penalizing hospitals that have high rates of Medicare beneficiaries being
readmitted to the hospital within 30 days of discharge. The readmission penalty has given hospitals a
strong incentive to improve care coordination across providers, and for that reason Medicare should
continue to implement the policy. In this report, the Commission suggests further refinements to
improve incentives for hospitals and generate program savings through reduced readmissions rather than
higher penalties.
Payments for hospice services. The Medicare hospice benefit provides beneficiaries an important
option for end-of-life care. At the same time, the Commission has identified several problems in the way
Medicare pays for hospices that may lead to inappropriate use of the benefit. The report presents
information on the prevalence of long-stay patients and the use of hospice services among nursing home
patients—both of which may inform policy development in the hospice payment system in the future. It
also presents further evidence to support the Commission’s March 2009 recommendations to revise the
hospice payment system.
Improving care for dual-eligible beneficiaries. Beneficiaries eligible for both Medicare and
Medicaid—many of whom have complex medical and social needs—often have trouble accessing
services and receive little care coordination, resulting in poorer health outcomes and higher spending
relative to other beneficiaries. Programs that coordinate dual-eligible beneficiaries’ Medicare and
Medicaid benefits have the potential to improve care for this population. In the report, the Commission
notes that federally qualified health centers and community health centers may be uniquely positioned to
coordinate care for dual-eligible beneficiaries because they provide primary care, behavioral health
services, and care management services, often at the same clinic site.
Mandated reports. The report includes three chapters that fulfill Congressional mandates: one on
Medicare ambulance add-on payments, a second on geographic adjustment of fee schedule payments for
the work effort of physicians and other health professionals, and a third on Medicare payment for
outpatient therapy services. In each case, the Commission considers the existing policies—which are not
permanent statutory provisions—and examines the effect of their continuation or termination on
program spending, beneficiaries’ access to care, and the quality of care beneficiaries receive, as well as
their potential to advance payment reform.
The three congressionally mandated reports are described in further detail in separate fact sheets, posted
on MedPAC’s website. The full report can be downloaded from MedPAC’s website:
http://medpac.gov/documents/Jun13_EntireReport.pdf
Read more about Medicare and Workers' Compensation
The Medicare Payment Advisory Commission (MedPAC) releases its June 2013 Report to the Congress:
Medicare and the Health Care Delivery System.
According to Commission Chair Glenn Hackbarth, “This report can inform a dialogue about future
directions for the Medicare program, as well as about technical refinements to existing Medicare
payment policy. Whether broad or narrow, the Commission’s work aims to balance the interests of
Medicare beneficiaries, health care providers, and tax payers.”
Redesigning the Medicare benefit. In the report, the Commission continues its discussion of
possible ways to redesign the Medicare benefit by focusing on the concept we refer to as competitively
determined plan contributions (CPC). Under CPC, Medicare beneficiaries could receive care through
either a private plan or traditional fee-for-service (FFS), but the premium paid by the beneficiary might
vary depending on the coverage option they choose. How much the federal government pays for a
beneficiary’s care would be determined through a competitive process comparing the costs of available
options for coverage. The report identifies key issues to be addressed if the Congress wishes to pursue a
policy option like CPC. These include how benefits could be standardized for comparability, how to
calculate the Medicare contribution, the role FFS, and the structure of subsidies for low-income
beneficiaries.
Reducing Medicare payment differences across sites of care. Medicare’s payment rates often
vary for similar services provided to similar patients, simply because they are provided in different sites of
care. For example, Medicare pays 141 percent more for one type of echocardiogram when done in a
hospital outpatient department than when it is done in a freestanding physician’s office. If Medicare pays a
higher rate for a service in one setting over another, program spending increases and beneficiaries pay
more in cost sharing without a corresponding increase in quality of care.
The Commission previously recommended reducing the rate Medicare pays for basic office visits from the
payment rate in the outpatient setting to the physician office rate. Using similar criteria, this report identifies
additional services that may be eligible for equalizing or narrowing payment differences across settings.
Bundling post-acute care services. Each year, about one-quarter of Medicare beneficiaries receive
care following a hospitalization from a post-acute care provider, such as a skilled nursing facility, home
health agency, or inpatient rehabilitation facility. However, nationwide the use of these services varies
widely, for reasons not explained by differences in beneficiaries’ health status. Under traditional
Medicare, the program pays widely varying rates for different settings and—characteristic of FFS—pays
based on the volume of care provided, without regard to quality or resource use.
Medicare has begun to explore the possibility of bundling services as a way to encourage providers to
coordinate and furnish needed care more efficiently. In this report, the Commission explores the
implications for quality and program spending for different design features of the bundles, such as the
services included, the length of time covered by the bundle, and the method of payment.
Reducing hospital readmissions. In 2008, the Commission recommended a hospital readmissions
reduction program to improve patient experience and reduce Medicare spending. In 2012, Medicare
began such a program, penalizing hospitals that have high rates of Medicare beneficiaries being
readmitted to the hospital within 30 days of discharge. The readmission penalty has given hospitals a
strong incentive to improve care coordination across providers, and for that reason Medicare should
continue to implement the policy. In this report, the Commission suggests further refinements to
improve incentives for hospitals and generate program savings through reduced readmissions rather than
higher penalties.
Payments for hospice services. The Medicare hospice benefit provides beneficiaries an important
option for end-of-life care. At the same time, the Commission has identified several problems in the way
Medicare pays for hospices that may lead to inappropriate use of the benefit. The report presents
information on the prevalence of long-stay patients and the use of hospice services among nursing home
patients—both of which may inform policy development in the hospice payment system in the future. It
also presents further evidence to support the Commission’s March 2009 recommendations to revise the
hospice payment system.
Improving care for dual-eligible beneficiaries. Beneficiaries eligible for both Medicare and
Medicaid—many of whom have complex medical and social needs—often have trouble accessing
services and receive little care coordination, resulting in poorer health outcomes and higher spending
relative to other beneficiaries. Programs that coordinate dual-eligible beneficiaries’ Medicare and
Medicaid benefits have the potential to improve care for this population. In the report, the Commission
notes that federally qualified health centers and community health centers may be uniquely positioned to
coordinate care for dual-eligible beneficiaries because they provide primary care, behavioral health
services, and care management services, often at the same clinic site.
Mandated reports. The report includes three chapters that fulfill Congressional mandates: one on
Medicare ambulance add-on payments, a second on geographic adjustment of fee schedule payments for
the work effort of physicians and other health professionals, and a third on Medicare payment for
outpatient therapy services. In each case, the Commission considers the existing policies—which are not
permanent statutory provisions—and examines the effect of their continuation or termination on
program spending, beneficiaries’ access to care, and the quality of care beneficiaries receive, as well as
their potential to advance payment reform.
The three congressionally mandated reports are described in further detail in separate fact sheets, posted
on MedPAC’s website. The full report can be downloaded from MedPAC’s website:
http://medpac.gov/documents/Jun13_EntireReport.pdf
Read more about Medicare and Workers' Compensation
May 18, 2013
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 ...
Mar 29, 2013
A new Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide has been posted and is available to be downloaded on the CMS (Centers for Medicare & Medicad Services) website.
Jan 11, 2013
"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 ...
Friday, May 17, 2013
Obamacare Will Be Collecting Workers' Compensation Medical Records
The implementation of Affordable Care Act data collection regulations will include the collection of medical information concerning work related accidents and injuries. The coalition of this information will broadly advance the concept of universal medical care and impose yet another route for the Centers for Medicare and Medicare to strengthen enforcement under the Medicare Secondary Payer Act.
The largest and most expansive database of personalized medical information is being established under the umbrella of an newly created unit under the authority granted to the Internal Revenue Service, The Federal Data Services Hub. Personal medical records, including electronic medical records, will be incorporated into the program.
"On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act
(P.L. 111-148). On March 30, 2010, the Health Care and Education Reconciliation Act of 2010
(P.L. 111-152) was signed into law. The two laws are collectively referred to as the Affordable
Care Act. The Affordable Care Act creates new competitive private health insurance markets –
called Exchanges – that will give millions of Americans and small businesses access to
affordable coverage and the same insurance choices members of Congress will have. Exchanges
will help individuals and small employers shop for, select, and enroll in high quality, affordable
private health plans that fit their needs at competitive prices. The IT systems will support a
simple and seamless identification of people who qualify for coverage through the Exchange, tax
credits, cost-sharing reductions, Medicaid, and CHIP programs. By providing a place for onestop shopping, Exchanges will make purchasing health insurance easier and more understandable
and will put greater control and more choice in the hands of individuals and small businesses."
Read more about "Federalization" and workers' compensation:
(P.L. 111-148). On March 30, 2010, the Health Care and Education Reconciliation Act of 2010
(P.L. 111-152) was signed into law. The two laws are collectively referred to as the Affordable
Care Act. The Affordable Care Act creates new competitive private health insurance markets –
called Exchanges – that will give millions of Americans and small businesses access to
affordable coverage and the same insurance choices members of Congress will have. Exchanges
will help individuals and small employers shop for, select, and enroll in high quality, affordable
private health plans that fit their needs at competitive prices. The IT systems will support a
simple and seamless identification of people who qualify for coverage through the Exchange, tax
credits, cost-sharing reductions, Medicaid, and CHIP programs. By providing a place for onestop shopping, Exchanges will make purchasing health insurance easier and more understandable
and will put greater control and more choice in the hands of individuals and small businesses."
Read more about "Federalization" and workers' compensation:
Friday, March 29, 2013
CMS Publishes Brand New Reference Guide for Medicare Set-Aside Arrangements
A new Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide has been posted and is available to be downloaded on the CMS (Centers for Medicare & Medicad Services) website.This reference guide was created to consolidate information currently found within the Workers’ Compensation Agency Services webpages and CMS Regional Office Program Memorandums, while providing WCMSA information to attorneys, Medicare beneficiaries, claimants, insurance carriers, representative payees, and
CMS cautions that parties should continue to visit their website for future updates to the reference guide, including additional details regarding the Workers’ Compensation Review Contractor’s review process.
Read more about WCMSA and workers' Compensation:
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 ...
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 ...
Monday, December 10, 2012
Federal court denies motion to add Medicare secondary reimbursement claims to a pending class action
A United States District Court handling Vioxx litigation has denied as application to add Medicare reimbursement claims to the pending application.
"The Court has reviewed the briefs and finds that denying leave to amend is appropriate because the proposed joinder of these new Defendant Law Firms is not the most expeditious way to dispose of the merits of these matters. First, the Court finds that the proposed amendment violates Federal Rule of Civil Procedure 20. The Court previously granted a motion to sever the Plan Plaintiffs' claims pursuant to Rule 21(a). See AvMed II, 2008 WL 4681368, at *5–8. As the Court held in AvMed II, the Plan Plaintiffs' bring different claims pursuant to different health benefit plan language to pursue liens over funds owed to different claimants in different factual circumstances. See id. This diversity between the claims of the individual Plan Plaintiffs meant that the rights to relief asserted did not arise out of the same transactions or occurrences and did not present common questions of law or fact. See id. (citing Fed.R.Civ.P. 20(a)). Therefore, the Court recognized the risk of “transform[ing] this litigation into an action against approximately 15,000 defendants, each of whom has entered into a separately negotiated health plan contract and each of whom has received medical benefits under highly individualized factual circumstances.” See id. at *8. Accordingly, the Court exercised its discretion to sever the improperly-joined claims of the individual Plan Plaintiffs."
....
Jon L.Gelman of Wayne NJ, helping injured workers and their families for over 4 decades, is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson).
In re Vioxx Products Liab. Litig., MDL 1657, 2012 WL 6045910 (E.D. La. Dec. 4, 2012)
Read more about Medicare Reimbursement Claims
Mar 17, 2009
A private suit, brought by a consortium of plaintiff entities and individuals seeking reimbursement of Medicare for the failure of the tobacco companies' to repay The Centers for Medicare and Medicaid [CMS] for benefits, was ...
Oct 01, 2010
The 11th Circuit Court of Appeals has held that Medicare is not entitled to reimbursement under the Medicare Secondary Payer Act (MSP) when the the surviving children's allocated share of proceed is the result of a wrongful ...
Dec 01, 2012
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 ...
Nov 22, 2011
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 ...
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 ...
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.
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