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:

"... 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 was
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. 

Haro v Sebelius, ___F.3d____, No. 11-16606, 2013 WL 4734032, Decided Sept.4, 2013.

Read prior posting about this case:

Federal Court Enjoins CMS From MSP Recovery Procedures

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 ...

http://workers-compensation.blogspot.com/

Workers' Compensation: Halted: Medicare Secondary Payer ...

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.

http://workers-compensation.blogspot.com/

….

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.

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Medicare to Partially Resume Workmens Comp Collection Letters

The Centers for Medicare and Medicaid Services (CMS)  has announced that its recovery of benefits contractor will resume sending Medicare collection letters to attorneys in workmens compensation cases. The practice was suspended recently following the entry of a Federal Court Order enjoining some recovery practices. 

CMS has a statutory obligation to seek recovery of medical benefits that it has paid to beneficiaries in those matters where Medicare is not the primary insurance carrier responsible for medical care. CMS seeks to recovery the money that it has apid from the workers' compensation insurance carrier. The process has evolved where in CMS sends notice to the attorneys in the pending workers' compensation claim seeking reimbursement at the time of resolution of the workers' compensation claim.

The Medicare Secondary Payer Recovery Contractor (MSPRC) is contracted to issue a letter know as the "Review of the Rights and Responsibility Letter" (RAR). The MSPRC has announced that the RAR letters will resume in some format on or about June 10, 2010.

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CMS Comments: "No Comment" on The Forthcoming Smart Act Regulations

CMS is withholding comment about The Smart Act regulations for now. See the transcript below:

"CENTERS FOR MEDICARE & MEDICAID SERVICES
Moderator: John Albert
07-25-13/1:00 p.m. ET
Confirmation # 11907630
Page 14

That’s all I have on that right now. Some of the areas sort of more high 
arching as oppose to just a single question. As we received a number of 
questions about the SMART Act and how it affects this process and what 
regulations are out there.

In terms of regulations, when CMS is doing an advance notice of proposed 
rulemaking, an ANPRM or NNPRM or final rules or even a federal registered 
notice, we’re not allowed to comment whether we are or are not doing that 
notice or the content of that until there is at least something on the unified 
regulatory agenda at which point we still can’t tell you specifics but we can 
tell you that document is in progress. The site you need to go to for that 
generally is – if I can find the right thing – is www.reginfo.gov. And what 
that – you can also find it simply by Googling the Unified Regulatory Agenda 
and then the term CMS. But what it lives on that, it won’t – and want – those 
are ones that are in our process – officially in the process.

And right now, the requirement in the SMART Act that an ANPRM be done 
with respect to civil money penalties under Section 111 is on that Regulatory 
Agenda. I believe there are at least two other MSP related regulations either –
whether it’s under something in the final rule, a pre rule or proposed rule. But 
you can check that out and that’s a site that you may want to monitor every so 
often if you have a question about whether or not we’re doing a particular 
regulation.

Similar to that, because I mentioned the SMART Act before, is a lot of the 
questions were asking specific facts about our specific actions we planned to 
take with respect to what’s in the SMART Act. As we make any changes or 
do anything related to the SMART Act, we – anytime instructions are going to 
change, we will give appropriate notice. At this point, there’s nothing that we 
have changed in our instructions that affects you at this time. So, we won’t be 
addressing any specific SMART Act questions.

Last but not least, as we have said in most of these calls, the extent we 
received questions that are related to MSP recoveries in the mailbox, those are 
outside the scope of this call. And we won’t be addressing those.

Read more about The Smart Act

Workers' Compensation: The SMART Act and Workers' Compensation

May 09, 2013

The SMART Act, which was signed into law by President Obama on January 10, 2013, amends and reforms the Medicare Secondary Payer Act to improve the reimbursement process. It is located in Title II of H.R. 1845 and ...

http://workers-compensation.blogspot.com/

It's Not "If", It's "When" - California - Workers' Compensation

Feb 01, 2013

Enactment of The SMART Act, the reality of which is that the regulations will eat up the statute, and also their lunch. I plan to write more on The SMART Act in the coming weeks. Maybe that wasn't so smart after all for the ...

http://workers-compensation.blogspot.com/

Workers' Compensation: Medicare Conditional Repayment ...

Jan 14, 2013

In additional to commenting on the new Strengthening Medicare And Repaying Taxpayers (SMART) Act, Judge Hickey will be discussing how the interaction of the workers' compensation claims process integrates with this ...

http://workers-compensation.blogspot.com/

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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.
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More CMS Resources: 

Check out our Blog, click here.

Check our our Website, click here.

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.

CMS Expands Options for Defense Submissions for CRCP

Commercial Repayment Center Portal (CRCP) Defense Submission Frequently Asked Questions

Recently a change was made to the portal that allows CRCP users to associate defenses to the individual claims included in recovery demands. This more granular response to demands, where Group Health Plans (GHPs) specify the basis of defense submissions, allows for more efficient and accurate reviews of the submitted defenses. What follows are answers to frequently asked questions received by the Commercial Repayment Center (CRC) in regard to this change. Additional details on the functionality are available in Version 3.2 of the CRCP User Guide, which is available in the “Reference Materials” section of the CRCP.

CMS: "The Smarter Act" Introduced in the US Senate

From the folks that brought you The Smart Act comes the sequel, "The Smarter Act." Senator Bill Nelson (D-FL) on July 31, 2014 introduced,  S.2731 - "A bill to amend title XVIII of the Social Security Act to provide for the application of Medicare secondary payer rules to certain workers' compensation settlement agreements and qualified Medicare set-aside provisions."

As you recall, since the Medicare Secondary Payer (MSP) was enacted in November 1980 to stop workers' compensation insurance carriers from shifting costs onto US taxpayers,  there has been a constant volley of activity between the Federal government, and those who want to maintain a status quo, ie. employers, insurance carriers and "other" financially interested participants. 

Congress and Medicare (Centers for Medicare and Medicaid Services [CMS]), in an effort to shore up the financially ailing Medicare program has been dueling with an employer/insurance company led coalition. The coalition successfully lobbied for The Smart Act  in May 2003. Mandated regulations were published and the stakeholders, including the coalition partners filed multiple comments objecting to the process. 

Purportedly S.2731 requires CMS to establish criteria: for review, calculations, time periods, appeals process, delivery of reimbursement, and  immunity form retroactive laws/regulations.

The latest round of coalition supported legislation is yet another attempt to curb the tidal wave that continues to erode the workers' compensation program as it historically existed since 1911 in the US. 

The real challenge to workers' compensation and its potential extinction, is whether the visionaries can look forward instead of backward. The future will be solutions to Medicare's fiscal integrity, the integration of the Affordable Care Act,  preventive health care, safer workplaces and globalization of the Social Security Disability Insurance (SSDI) system.

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CMS is Hosting A Webinar on Insurance Plan Appeals

Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Applicable Plan Recovery Webinar: Appeals Thursday, September 24, 2020 1:00pm ET

CMS Issues Series of Mandatory Reporting Alerts

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.

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CMS Gearing Up for Mandatory Insurance Reporting

CMS will implement mandatory insurance company reporting: GHP January 1, 2009 and liability insurance carriers (workers’ compensation) on July 1, 2009. Mandatory reporting announcements will be posted on the CMS web site and e-mail notices may be requested by e-mail

The new provisions for Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers' Compensation found at 42 U.S.C. 1395y(b)(8):

Add reporting rules; do not eliminate any existing statutory provisions or regulations. The new provisions do not eliminate CMS' existing processes if a Medicare beneficiary (or his/her representative) wishes to obtain interim conditional payment amount information prior to a settlement, judgment, award, or other payment.

Include penalties for noncompliance.

Who must report: "an applicable plan." "…[T]he term 'applicable plan' means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan or arrangement: (i) Liability insurance (including self-insurance). (ii) No fault insurance. (iii) Workers' compensation laws or plans."

What must be reported: the identity of a Medicare beneficiary whose illness, injury, incident, or accident was at issue as well as such other information specified by the Secretary to enable an appropriate determination concerning coordination of benefits, including any applicable recovery claim.

When/how reporting must be done:

• In a form and manner, including frequency, specified by the Secretary.

• Information shall be submitted within a time specified by the Secretary
after the claim is resolved through a settlement, judgment, award, or other
payment (regardless of whether or not there is a determination or
admission of liability).

• Submissions will be in an electronic format.

Government Appeals Case Involving MSP Statute of Limitations

A Notice of Appeal has been filed by the United States in a case where a Federal District Court held that the statute of limitations in a Medicare Secondary Payer Act recovery action was limited to only 6 years. The government contented in the matter that the statute of limitations for it to assert recovery/reimbursement was extended under the "implied contract theory."

The case was tried in the U.S. District Court, Northern District of Alabama (Eastern) before Judge Karon O. Bowdre and involved a contract reimbursement claim under the Medicare Act, specifically 425 USC 1395 (HHS). A Final Order was entered on September 13, 2011 the the United States filed a Notice of Appeal on October 11, 2011.

Read the prior posting: CMS Has 6 Year Statute of Limitations-Court Dismisses MSP Recovery Claim 10.1.2010

United States of America v James J. Stricker, et al., CV 09-BE-2423-E (USDCT ND Alabama)

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CMS to Host Webinar: Commercial Repayment Center Contractor Transition

Commercial Repayment Center Contractor Transition Webinar for Non-Group Health Plans on Thursday, January 18, 2018 

Effective February 8, 2018, a new contractor will assume the responsibility of the Medicare Commercial Repayment Center (CRC) functions.

CMS Set-Aside Rules Raise Concern of Civil Trial Bar

At a recent continuing legal education program in Wisconsin members of the plaintiff and defense civil trial bar raised their concerns over the Rules governing CMS set-aside arrangements. While both sides recognized the need to reimburse Medicare, the methods being utilized by CMS to obtain reimbursement of future medical expenses caused deep concern by the lawyers.

Click here to read more about CMS Set-aside arrangements.

Federal Court Deems CMS Interpretation of the MSP Act Impenetrable

A UD District Court has denied a health provider's challenge to CMS's interpretation of the to the Medicare Secondary Act. CMS's formula for reimbursement was upheld.

"The Court finds this line of argument unpersuasive for several reasons. Most significantly, Allina's heavy reliance on the above-cited cases is unavailing because none of those decisions directly dealt with the precise issue before this Court–i.e., the phrase “entitled to benefits under Part A.” Rather, all of those courts were called upon to interpret the other component of the Medicaid fraction's numerator–the requirement that patients be “eligible” for Medicaid. For this very reason, our Court of Appeals “declined to follow” those same cases, characterizing those courts' discussion of the phrase “entitled to benefits” as dicta. Northeast Hosp., 657 F.3d at 12 n.7. This Court agrees with that assessment and follows the lead of our Circuit. Those decisions do not lend any meaningful support to Allina's arguments here. Moreover, the D.C. Circuit has rejected the substance of this “eligible” versus “entitled” argument as unpersuasive in any event, observing in Northeast Hospital that “the fact that the DSH factions speak of ‘eligibility’ for Medicaid but ‘entitlement’ to Medicare” was not “enlightening.” Id. at 12. Instead, as the Circuit went on to state, “the Secretary's interpretation of ‘entitled’ as ‘meeting the statutory criteria for entitlement’ ... does not actually collapse the terms.” Id. (explaining that an individual could be “ ‘eligible’ for, but not ‘entitled’ to, Part A benefits because one has not yet ‘enrolled’ in the program”). This Court concurs. The Secretary's reading of the statute at issue here does not equate these two terms, and Allina's insistence otherwise lacks merit."

Allina Health System v. Sebelius,

--- F.Supp.2d ----, 2013 WL 5530609, D.D.C., October 08, 2013 (NO. 09-CV-1889 (RLW))

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CMS/MSP Not Going To Require Pre 12/5/1980 Exposure Reporting, BUT....

CMS will not require reporting of claim data where the exposure occurred prior to 12/5/1980 (Effective date of the MSP Act), but if exposure continues after that date, that is another story.

"We were asked about the 12/5/80 date for liability and no fault and the date of incident. Yes we say that in general CMS is determined that it won’t pursue recovery if the date of CMS defined date of incident is prior to 12/5/1980. But then we give an example of a situation with a continuing DOI specifically with respect to exposure.

"If it’s easier for you to think of it that way, if you have a situation with exposure and that exposure continues on or after 12/5/80 it’s really like you’ve got a series of continuous multiple DOIs and we only require you to report the first DOI but yes we do have a recovery claim in that situation.
Transcript of Teleconference 3/24/1980, page 12

CMS Implements SMART Act Functionality for Repayment

The Workers' Compensation community of stakeholders lobbied strenuously through 2012 for revision of the conditional payment process utilized by the Centers for Medicare and Medicaid (CMS). The SMART Act of 2012 codifies the process to comply with the Medicare Secondary Payer Act. CMS has now implemented an on-line process to facilitate reimbursement:

CMS - ICD10 Codes in Effect for Reporting Requirements Oct 1, 2015

Medicare Secondary Payer Act - CMS Reporting Requirements ICD10 Codes to be required as of October 1, 2015.

Reporting Reminder: Effective October 1, 2015, Responsible Reporting Entities and their agents will be required to report ICD-10-CM diagnosis codes on claim reports with a CMS Date of Incident (DOI) on or after October 1, 2015. This timeline and reporting requirements have not changed. For more information on ICD diagnosis code reporting, please refer to the MMSEA Section 111 NGHP User Guide Technical Information Chapter IV (Section 6.2.5 – ICD-9 and ICD-10 Codes). The NGHP User Guide can be downloaded from the NGHP User Guide page available at the following link: http://go.cms.gov/MIRNGHPUserGuide.

Workers’ Compensation Medicare Set-Aside Portal (WCMSAP)

The Centers for Medicare & Medicaid Services (CMS) is currently Pilot Testing the Workers' Compensation Medicare Set-aside Portal (WCMSAP), a web-based application. This new initiative will allow submitters of Workers' Compensation Medicare Set-Aside Arrangements (WCMSAs) to directly enter case information, upload documentation, and receive case status information through the use of a secure Web portal. 

This secure Web portal will greatly improve the efficiency of the submission process for WCMSAs, including receipt of the proposal by its Workers' Compensation Review Contractor (WCRC). The WCMSAP, a web-based application, will allow attorneys, beneficiaries, claimants, insurance carriers, representative payees, and WCMSA vendors to:

• Create a work-in-progress case
• Submit WCMSA cases
• Perform case lookups
• Append documentation to a case

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Annual Reporting of WCMSA Account Expenditures

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 (WCMSA) Account Expenditure accounting documentation to the CMS lead Medicare Contractor at the address below:

MSPRC - Non-Group Health Plan (NGHP)
P.O. Box 138832
Oklahoma City, OK 73113

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CMS Updates Submission Process for WCMSAs

CMS has announced two changes for the WCMSA submission process:

1. Updated checklist; and

2. Intent to provide a secure portal for submission of WCMSAs.

"Good news, over 85 responses were received to the "Survey for Workers' Compensation Medicare Set-Aside (WCMSA) Process." The results confirm entities who report workers' compensation settlements that contemplate future medical (including prescription drug) treatments support, overwhelming the availability of a secure Internet web-based portal or interface. Further, the vast majority of responders stated that they are capable of uploading and transmitting documentation in a PDF format into a secure Internet web based portal application.

Based on the results, CMS will be moving forward with its plan to make available a secure Internet web-based portal or interface for the WCMSA submission process."

For more information about CMS and WCMSAs click here.

CMS Prohibited From Collecting for Unrelated Conditions

A Federal Court in California has prohibited the Center for Medicare and Medicaid Services (CMS) from seeking reimbursement of conditional payments when the medical codes for the conditions are unrelated or not related even if the primary code was for a work-related medical condition. The court made the following ruling in a motion for partial summary judgment in a declaratory judgment action.