Copyright

(c) 2022 Jon L Gelman, All Rights Reserved.

Pandemic Preparedness Experts

Pandemic Preparedness Experts
COVID Safe Workplaces
Showing posts sorted by relevance for query CMS. Sort by date Show all posts
Showing posts sorted by relevance for query CMS. Sort by date Show all posts

Thursday, June 27, 2013

CMS Consolidates Web Portals for Coordination of Benefits & Recovery

The Coordination of Benefits and Medicare Secondary Payer Recovery sections on the Medicare tab of the CMS.Gov Web Site have been combined into a single, comprehensive section titled, Coordination of Benefits & Recovery.  

The Web Site redesign consolidates information into groupings by audience and topic. To
access the new web pages, go to www.cms.gov and click on the Medicare tab near the top of the page. Once the Medicare page loads, scroll down to the Coordination of Benefits & Recovery section and select any of the links available.

CMS provides the ability for you to be automatically notified when changes are made to a section under Coordination of Benefits & Recovery. 

To sign-up for these notifications, select one of the Web Site links (e.g. Insurer Services) and click on the Sign-up Notification link found in the Related Links area near the bottom of the page. You will be asked to supply your email address and then be taken to a selection page. Scroll to the Coordination of Benefits & Recovery heading and select the section or sections for which you wish to receive notifications. When new information is added to a section you have selected, you will be notified via email.

For those users that regularly visit the Web Site, short-cut links have been created for ease of access:

Coordination of Benefits & Recovery Overview: http://go.cms.gov/cobro  

Attorney Services:  http://go.cms.gov/attorney

Beneficiary Services:   http://go.cms.gov/bene

COBA Trading Partners:  http://go.cms.gov/cobatp

Employer Services:  http://go.cms.gov/employer

Insurer Services:  http://go.cms.gov/insurer

Prescription Drug Assistance Programs:   http://go.cms.gov/pdap

Provider Services:   http://go.cms.gov/provider
  
Mandatory Insurer Reporting For Group Health Plans:  http://go.cms.gov/mirghp 

Mandatory Insurer Reporting For Non Group Health Plan:  http://go.cms.gov/mirnghp

Workers’ Compensation Medicare Set-Aside Arrangements:  http://go.cms.gov/wcmsa


Monday, June 1, 2015

GAO calls for better Medicare fee setting data and more transparency

Many state workers' compensation medical fee schedules are based upon Medicare rates. A new study from US Government Accounting Office reports that the underlying rate making scheme is biased and the GAO recommends increased transparency of the process.

The American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) has a process in place to regularly review Medicare physicians' services' work relative values (which reflect the time and intensity needed to perform a service). Its recommendations to the Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare, though, may not be accurate due to process and data-related weaknesses. 

First, the RUC's process for developing relative value recommendations relies on the input of physicians who may have potential conflicts of interest with respect to the outcomes of CMS's process. While the RUC has taken steps to mitigate the impact of physicians' potential conflicts of interest, a member of the RUC told GAO that specialty societies' work relative value recommendations may still be inflated.

RUC staff indicated that the RUC may recommend a work relative value to CMS that is less than the specialty societies' median survey result if the value seems accurate based on the RUC members' clinical expertise or by comparing the value to those of related services.

Second, GAO found weaknesses with the RUC's survey data, including that some of the RUC's survey data had low response rates, low total number of responses, and large ranges in responses, all of which may undermine the accuracy of the RUC's recommendations. For example, while GAO found that the median number of responses to surveys for payment year 2015 was 52, the median response rate was only 2.2 percent, and 23 of the 231 surveys had under 30 respondents.

CMS's process for establishing relative values embodies several elements that cast doubt on whether it can ensure accurate Medicare payment rates and a transparent process.

First, although CMS officials stated that CMS complies with the statutory requirement to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews.

Second, CMS's process is not fully transparent because the agency does not publish the potentially misvalued services identified by the RUC in its rulemaking or otherwise, and thus stakeholders are unaware that these services will be reviewed and payment rates for these services may change.

Third, CMS provides some information about its process in its rulemaking, but does not document the methods used to review specific RUC recommendations. For example, CMS does not document what resources were considered during its review of the RUC's recommendations for specific services.

Finally, the evidence suggests—and CMS officials acknowledge—that the agency relies heavily on RUC recommendations when establishing relative values. For example, GAO found that, in the majority of cases, CMS accepts the RUC's recommendations and participation by other stakeholders is limited. Given the process and data-related weaknesses associated with the RUC's recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.

CMS has begun to research ways to develop an approach for validating RUC recommendations, but does not yet have a specific plan for doing so. In addition, CMS does not yet have a plan for how it will use funds Congress appropriated for the collection and use of data on physicians' services or address the other data challenges GAO identified.

Why GAO Did This Study
Payments for Medicare physicians' services totaled about $70 billion in 2013. CMS sets payment rates for about 7,000 physicians' services primarily on the basis of the relative values assigned to each service. Relative values largely reflect estimates of the physician work and practice expenses needed to provide one service relative to other services.

The Protecting Access to Medicare Act of 2014 included a provision for GAO to study the RUC's process for developing relative value recommendations for CMS. GAO evaluated (1) the RUC's process for recommending relative values for CMS to consider when setting Medicare payment rates; and (2) CMS's process for establishing relative values, including how it uses RUC recommendations. GAO reviewed RUC and CMS documents and applicable statutes and internal control standards, analyzed RUC and CMS data for payment years 2011 through 2015, and interviewed RUC staff and CMS officials.

What GAO Recommends
CMS should better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. CMS should also develop a plan for using funds appropriated for the collection and use of information on physicians' services in the determination of relative values. HHS agreed with two of GAO's recommendations, but disagreed with using rulemaking to inform the public of RUC-identified services. GAO clarified that the recommendation is not limited to rulemaking.

Click here to read the full report.
Better Data and Greater Transparency Could Improve Accuracy
GAO-15-434: Published: May 21, 2015. Publicly Released: May 21, 2015.


Sunday, December 19, 2021

CMS Announces 2022 Workers' Compensation Recovery Threshold to Remain at $750.00

Computation of Annual Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers' Compensation Settlements, Judgments, Awards, or Other Payments for 2022 were announced this week.

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.

Thursday, February 21, 2013

CMS Announces New WCMSA Re-Evaluation Procedure

February 12, 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 believes that a CMS determination:

• contains obvious mistakes, such as mathematical errors or a failure to recognize that medical records already submitted show a surgery CMS priced has already occurred, or
• misinterpreted evidence previously submitted, a re-evaluation maybe requested.  

Please refer to  Question # 12 of the July 11, 2005, procedure memorandum located in the “downloads” section of this page for detailed information regarding when a  re-evaluation request maybe submitted.  The CMS Regional Offices will continue to review the requests submitted through the portal.

Posted on CMS Workers Compensation Agency Services

Read more about WCMSA and workers' compensation 

Jan 03, 2012
Address for submitting annual accounting documentation to CMS' Medicare Secondary Payer Recovery Contractor (MSPRC). Please send your completed annual Workers' Compensation Medicare Set-aside Arrangement ...
 
Dec 19, 2008
The Centers for Medicare and Medicaid Services (CMS) has now published a copy of its Operating Rules regarding the evaluation of set-aside proposals. CMS cited that distribution of this material may reduce review time by ...
 
Jun 06, 2008
CDC in Reviewing WCMSA Limits Review to One Life Expectancy Table. Effective July 1, 2008 the Centers for Medicare and Medicad (CMS) will exclusively use the Centers for Disease Control (CDC) Table 1 (Life Table for ...
 
Sep 10, 2009
CMS Lists How to Avoid 10 Top WCMSA Errors. The Centers for Medicare and Medicaid Services has now posted the 10 top errors on Workers' Compensation Set Aside Agreement submissions and how to avoid them: 1.

Tuesday, March 9, 2010

Citing Violations Medicare Ends Contract with Fox Insurance Company Drug Plan

The Centers for Medicare and Medicaid Services has issue an announcement of the immediate termination of Fox Insurance Company.

Members Will Be Provided Access to Drugs While Transitioning to New Plans.

The Centers for Medicare & Medicaid Services (CMS) today terminated its contract with Fox Insurance Company. After an onsite review of the plan and its services, CMS determined that the plan’s significant deficiencies – not meeting Medicare’s requirements to provide enrollees with prescription drugs according to recognized standards of care – jeopardized the health and safety of Fox enrollees. CMS found that Fox committed a series of violations, including improperly denying its enrollees coverage of critical HIV, cancer, and seizure medications. The termination of the contract is effective immediately.

The immediate termination will not impact or delay access to drugs for the more than 123,000 Medicare beneficiaries currently enrolled in Fox plans. Beginning tomorrow, all enrollees will obtain their drugs through LI-NET, a program run by Medicare and administered by Humana, to ensure that beneficiaries receive their Medicare prescription drugs. Fox enrollees will be able to choose a new Medicare prescription drug plan through May 1, 2010. Current enrollees who do not choose a plan will be enrolled into a new plan by Medicare.
“The immediate termination of Fox as a Medicare prescription drug plan demonstrates our commitment to protecting the health of some of their most vulnerable enrollees from getting necessary drugs, in some cases life-sustaining medicines. CMS’s immediate action was essential to protect members’ health and safety – an integral part of our contract with all Medicare beneficiaries,” said Jonathan Blum, acting director of CMS’ Center for Drug and Health Plan Choices. “Fox enrollees also need to know that they are not losing their drug coverage and will continue to have access to needed medicines. We will be sending letters explaining the steps we are taking to ensure they continue to get their medicines. They can also call 1-800-MEDICARE or their local state health insurance assistance programs if they have questions.”

CMS issued an enrollment and marketing sanction to Fox on Feb. 26, 2010, because the organization was not following Medicare’s rules for providing prescription drug coverage to its enrollees. After an onsite audit, which ran between March 2 and March 4, CMS found Fox’s problems persisted and it continued to subject its enrollees to obstacles in getting needed and, in many cases, life–sustaining medicines. CMS also found that many of the obstacles were in place to limit access to high-cost drugs, which could have led to enrollees’ clinical needs not being met. In many cases, Fox enrollees were required to have unnecessary and invasive medical procedures before they were able to obtain drugs. Fox was unable to satisfactorily address these compliance concerns and furnish medicines to its Medicare enrollees.

Among the audit findings CMS found include:

· Failing to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law.

· Not meeting the plan’s appeals deadlines,

· Not complying with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.

· Failing to notify enrollees about prior authorization and step therapy determinations as required by Medicare.

According to CMS auditors, Fox was unable to satisfactorily address compliance concerns cited in the enrollment and marketing sanction and meet contractual obligations to provide medicines to Medicare beneficiaries enrolled in their plans.

“We take our oversight role of Medicare prescription drug plans seriously,” said Blum. “We review and take action on all complaints received about Medicare health and drug plans and will take appropriate and immediate actions wherever necessary.”

CMS encourages Medicare prescription drug plan enrollees having concerns with access to drug coverage to contact 1-800-MEDICARE (1-800-633-4227) or the state health insurance assistance program (SHIP) to help get them resolved. Medicare enrollees, their families and their caregivers can contact a SHIP near them by visiting:http://www.medicare.gov/Contacts/staticpages/ships.aspx

# # #

NOTE: States in which the Fox plan was available were: Arkansas, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Maryland, Missouri, North Carolina, New Jersey, New York, Nevada, Ohio, Pennsylvania, South Carolina, Texas and West Virginia.

Monday, June 5, 2017

Chaos for Workers' Compensation Programs--The Elimination of Social Security Numbers?

The Centers for Medicare & Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security Numbers (SSN) from Medicare cards to help combat identity theft and safeguard taxpayer dollars. The question remains whether the elimination will cause chaos in state workers' compensation programs since the SSNs have historically been utilized as personal identifiers.

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


Saturday, March 21, 2009

CMS Publishes a User Manual for MSP Reporting

The Centers for Medicare and Medicaid Services (CMS) has now published a User Manual. The manual details the federal procedures that will be utilized to implement Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA Section 111).

July 1, 2009 is the implementation date for mandatory reporting in workers' compensation claims. Section 111 adds reporting requirements and does not eliminate any existing statutory provisions or regulations. CMS' existing processes, including for example, CMS’ process for self-identifying pending liability insurance (including self-insurance), no-fault insurance, or workers’ compensation claims to CMS’ Coordination of Benefits Contractor (the COBC) or the processes followed by CMS’ Medicare Secondary Payer Recovery Contractor (the MSPRC) for MSP recoveries, remain undisturbed. The Act does impose penalties for noncompliance.

CMS has announced that it will offer a "query function" to required reporting entities to ascertain whether or not the claimant is a Medicare beneficiary. The query will be based upon identifying data including: HICN or SSN; first initial of the last name; first 6 characters of the last name; date of birth and gender.

Yet to be determined are a host of reporting issues including:

  • Interim dollar reporting threshold for "Total Payment Obligation to the Claimant" (TPOC) amounts -- CMS’s decision on this issue will be released separately in the near future.
  • Interim dollar reporting threshold for "Ongoing Responsibility for Medicals" (ORM) -- CMS has this issue under consideration.
  • Further information regarding reporting for mass torts – This issue is still under discussion.
  • ICD9 Codes – CMS is reviewing the codes to determine if there are certain codes which Responsible Reporting Entities (RREs) will be prohibited from submitting.
  • Examples regarding "Who is the RRE" -- CMS is reviewing additional examples submitted by the industry for possible inclusion in the User Guide.

Tuesday, January 18, 2022

CMS Health Care Workers Vaccination Deadline March 15, 2022


The Centers for Medicare and Medicaid Services (CMS) issued
guidance that the full vaccination compliance deadline is March 15, 2022, for all health care workers subject to the Omnibus Health Care Staff Vaccination rule.

Tuesday, November 30, 2021

CMS stopped from imposing vaccine mandate

The Centers for Medicare and Medicaid Services [CMS] has been halted from imposing a vaccine mandate on a wide range of healthcare facilities. A federal court in Missouri found in favor of a group of 11 Republican states when it issued an injunction against the proposed rule.

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
WCMSA vendors.   

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 ...

Friday, December 28, 2012

Legislation Goes to President Obama on CMS Condition Payment Procedures

The US House (H.R. 1845) and US Senate has passed legislation to modify procedures for processing conditional payments under the Medicare (S. 1718) Secondary Payer Act. It establishes parameters for repording, processing and appealing issues concerning conditional payments.

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 ...


Friday, September 30, 2011

CMS Announced Status Update and Future Changes

As part of the Centers for Medicare & Medicaid Service (CMS) efforts to continuously improve its Medicare Secondary Payer (MSP) program; CMS has posted the following information to the MSP websites:

1) An ALERT delaying the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Section 111 MSP reporting requirement for certain liability insurance (including self-insurance) settlements, judgments, awards, or other payments is now posted at www.cms.gov/MandatoryInsRep.

2) Policy guidance related to Exposure, Ingestion, and Implantation issues, and December 5, 1980, is now posted at www.cms.gov/MandatoryInsRep and www.cms.gov/COBGeneralInformation.

3) An ALERT related to Qualified Settlement Funds, under Section 468B of the Internal Revenue Code, is now posted at www.cms.gov/MandatoryInsRep.

4) A policy memorandum, for liability insurance (including self-insurance), on the acceptance of the treating physician's certification, and its impact on the issue of protecting Medicare's interests with respect to future medicals is now posted at www.cms.gov/COBGeneralInformation.

In addition, on September 30, 2011, the MSPRC will implement a self-service information feature to its customer service line. This feature gives callers the ability to get the most up-to-date Demand/Conditional Payment amounts, and the dates that those letters were issued, without having to speak to a customer service representative. The self-service feature will be available for extended hours, and callers will have the option of requesting information on multiple cases during one phone call.

Beginning in October 2011, CMS will implement an option to pay a fixed percentage of certain physical trauma-based liability cases with settlement amounts of $5000 or less. Detailed information on this option will be posted as an ALERT, on or before October 21, 2011, on the MSPRC website at www.MSPRC.info.

Upcoming improvements to the MSP program, expected within the next 3-9 months, include the following:

• The implementation of a MSPRC portal, where the beneficiary/representative can obtain information about Medicare's claim payments, demand letters, etc., and input information related to a settlement, disputed claims, etc.

• The implementation of an option that allows for an immediate payment to Medicare for future medical costs that are claimed/released/effectively released in a settlement.

• The implementation of a process that provides Medicare's conditional payment amount, prior to settlement in certain situations.

Monday, May 23, 2011

CMS Announces Review is Only a Recommended Process for Set-Aside Agreements

The Centers for Medicare and Medicaid Services (CMS) has just announced a clarification of its prior memos concerning the review of Workers Compensation proposed Set Aside Agreements and also indicates that submission is an elective process.

"Submission of a WCMSA proposal to CMS for review and approval is a recommended process. There are no statutory or regulatory provisions requiring that a WCMSA proposal be submitted to CMS for review. However, if an entity chooses to use the WCMSA review process, CMS requests that it comply with the established policies and procedures referenced on its Web site. Claimants, employers, carriers, and their representatives should be encouraged regularly to monitor this dedicated workers’ compensation Web site for changes in policies and procedures."

CMS indicated that, "A WCMSA should not be submitted to CMS when the resolution of the workers’ compensation claim results in the medical portion of the claim is being left open." In the memo, CMS reiterates the threshold levels and eligibility for review criteria.


Related articles

Wednesday, May 18, 2011

Federal Court Enjoins CMS From MSP Recovery Procedures

A US District Court Judge in Arizona has certified a putative class, composed of a nationwide class of Medicare recipients challenging the recovery procedures utilized by The Centers for Medicare and Medicaid Services (CMS). The Court also issued an Order enjoining CMS from certain collection activities.

This follows a broad discovery ordered issued by the Court a year ago. Haro v. Sebelius, 2010 WL 1452942 (A. Ariz.) CV 09-134 TUC DCB, Decided April 12, 2010.The plaintiffs were permitted discovery beyond the administrative record. The class action is challenging the recovery procedures of CMS under the Medicare Secondary Payer Act (MSP). The discovery permitted will included depositions and expert evidence .

The Court Order enjoins CMS from certain actions:
"IT IS FURTHER ORDERED that Defendant's demand for payment of her MSP reimbursement claims, under threat of collection actions before there has been a resolution of an appeal regarding the amount of the Defendant's MSP claim or a waiver request, exceeds her authority under the Medicare statute, and Defendant is enjoined from demanding payment of a MSP reimbursement claim with threats of commencing collection actions before there is a resolution of an appeal or waiver request. 
"IT IS FURTHER ORDERED that the Defendant's demand that attorneys withhold liability proceeds from clients pending payment of amounts claimed by the Defendant as MSP reimbursement exceeds her authority under the Medicare statute, and Defendant is enjoined from demanding that attorneys withhold liability proceeds from their clients pending payment of disputed MSP reimbursement claims.
In reaching its decision to allow discovery, the Court held that the putative class, that is challenging the recovery methods of Medicare, is permitted to extend discovery beyond the limited administrative record action without the necessity of the exhaustion of administrative remedies since constitutional and due process were collateral to any individual claim.

The issues reviewed by the court were:
"1) whether Defendant [CMS] can require prepayment of an MSP recovery claim before the correct amount is determined through the administrative appeal procedures, and
2) whether Defendant [CMS] can make plaintiffs' attorneys financially responsible if they do not hold or immediately turn over to the Defendant [CMS] their clients' litigation proceeds.

These questions involve a due process analysis, which consists of a three part balancing test:
1) the private interest affected;
2) the risk of erroneous deprivation and probable value of additional safeguards, and
3) the government or public interest in current procedures. "


Haro v. Sebelius, (A. Ariz.) CV 09-134 TUC DCB

Thursday, July 9, 2015

CMS Announces Changes to Physician Fee Schedules: End of Life Care Discussion Payments Proposed

Under a new proposal announced by the Centers for Medicare and Medicaid Services, physicians will be paid to discuss "end of life care" with patients. 

Today, CMS released the first proposed update to the physician payment schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal includes a number of provisions focused on person-centered care, and continues the Administration’s commitment to transform the Medicare program to a system based on quality and healthy outcomes.

“CMS is building on the important work of Congress to shift the Medicare program toward a system that rewards physicians for providing high quality care,” said Andy Slavitt, Administrator of CMS. “Thanks to the recent landmark Medicare and children’s health insurance program legislation, CMS and Congress are working together to achieve a better Medicare payment system for physicians and the American people.”

In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the Department to move the Medicare program to a health care system focused on the delivery of quality care and value.

The proposed rule includes updates to payment policies, proposals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Reporting System, which measures the quality performance of physicians participating in Medicare, and updates to the Physician Value-Based Payment Modifier, which ties a portion of physician payments to performance on measures of quality and cost. CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries.

The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.

The release of the rule triggers a 60-day comment period, during which time CMS welcomes the input of stakeholders and the public. A final rule will be published this fall. For a fact sheet on the proposed rule, Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule for Calendar Year 2016, please see here. For further information, please see the rule on display here.

Tuesday, April 2, 2013

CMS Hosting a Town Hall Event for WCMSA


Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Town Hall  Event

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 matters that are not case specific.


In an effort to address as many topics as possible, CMS is requesting stakeholders to submit non-case specific questions they would like to have addressed during the teleconference to the CMS MSP Central mailbox* prior to the teleconference. CMS will review and categorize the questions submitted and attempt to answer as many questions as possible during the teleconference. There may also be an opportunity for the stakeholders to ask questions after the presentation.

Date of Teleconference:   April 11, 2013
Call-in time for all calls:   2:30-4:30p.m. EST
Call-in line:                          (800) 603-1774
Pass Code:                           WCRC
Questions for call:            Please submit to CMS mspcentral@cms.hhs.gov*

Questions may be submitted beginning April 1, 2013 thru April 5, 2013 @ 3:30 p.m. EST.
All questions submitted for the teleconference to the email address shown above should clearly state in the subject line “WCRC April 11, 2013 Town Hall Teleconference.”  

Note: Questions submitted to the mailbox after the date and time noted above will not be considered.


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


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 ...