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Monday, April 8, 2013
CMS Defines Further Defines Policy Implementation on Part D Coverage of Benzodiazepines and Barbiturates
Wednesday, July 3, 2013
Medicare Classifies Over 9.6 Billion Each Year as Overpayments-Some Are Uncollectible
Related articles
- CMS Consolidates Web Portals for Coordination of Benefits & Recovery
- NJ Workers Compensation Companies Pay More for Hospital Fees
- NJ Court Approves Medicare Set-Aside Agreement Lacking CMS Review
- Misclassification Fraud Across the Country
- State Law Does Not Preempt State Medical Authorization Criteria
Saturday, December 13, 2008
Federal Appeals Court Upholds Constitutional Challenge Against CMS Memo
The Court ruled:
"This suit arose after CMS clearly rejected such use of § 411.47, declaring that it applies only to medical expenses incurred before the workers' compensation settlement. In a memorandum issued on July 11, 2005 (the 2005 Memo), it said.
Q11. Compromising of Future Medical Expenses-Does CMS compromise or reduce future medical expenses related to a [workers' compensation] injury?
A11. No. Some submitters have argued that 42 C.F.R. § 411.47 justifies reduction to the amount [set aside for Medicare in a workers' compensation settlement]. The compromise language in this regulation only addresses conditional (past) Medicare payments. The CMS does not allow the compromise of future medical expenses related to a [workers' compensation] injury."
"In light of this precedent, we conclude that Protocols has suffered an actual injury. It admits that it has arranged settlements that are contrary to what CMS has declared to be required. As a result, CMS may sometime in the future demand that Protocols reimburse Medicare for Protocols' portion of settlement proceeds. And according to affidavits submitted by Protocols, this potential liability has a present impact on its business-that is, the contingent liability has created an actual and imminent injury."
07-1175 - Protocols, LLC v. Leavitt (12/11/2008)
Saturday, May 18, 2013
NJ Court Approves Medicare Set-Aside Agreement Lacking CMS Review
"The court has thoroughly reviewed the sworn testimony of plaintiffs' expert regarding the proposed set-aside amounts for future medical expenses relating to the
underlying accidents/incidents, which would otherwise be covered or reimbursable
by Medicare. The court finds that the proposed set-aside amount in each case
fairly takes Medicare's interests into account in that the figures are both reasonable and reliable. Therefore, the court is satisfied that Medicare's interests
have been adequately protected pursuant to the MSP. Plaintiffs shall set aside the
proposed sums in self-administered interest-bearing accounts to be used solely for
the purpose of satisfying future medical expenses related to the underlying accidents/incidents."
DUHAMELL, Plaintiff v. RENAL CARE GROUP EAST, INC., RCG Southern New Jersey, LLC, Philadelphia Suburban Development Corporation, Defendants. Catherine A. Ney, Plaintiff, et al,, --- A.3d ----, 2013 WL 2102701 (N.J.Super.A.D.) Decided Dec. 7, 2012. May 16, 2013.
Friday, December 19, 2008
CMS Publishes WCMSA Operating Rules
The Operating Rules, an 11 page document, highlights the procedures to be utilized by CMS. They instruct CMS on how to respond to telephone quires including specific instructions such as, "Do not give recommended amounts or expected completion dates." The Rules also instruct CMS contractor to consider the Total Settlement Amount (TSA) if the claimant has multiple workers' compensation cases and suggest one Recommended MSA (RMSA). Therefore "apportioning" multiple claims into a series of cases below the threshold level will not avoid CMS scrutiny. Also legal malpractice awards based on the mishandling of the workers' compensation claims are deemed not to be payments of compensation.
The Operating Rules were previously made available under a Freedom of Information Request in October 2008. The Operating Rules have been posted in redacted form and will be updated periodically by CMS.
Tuesday, January 12, 2010
The Grey Area of the CMS Statute of Limitations for a Recovery Action
Sunday, February 5, 2017
Judge Accepts Medicare’s Plan To Remedy Misunderstanding On Therapy Coverage
"A federal judge has accepted Medicare’s plans to try once more to correct a commonly held misconception that beneficiaries’ are eligible for coverage for physical and occupational therapy and other skilled care only if their health is improving.
"'Confusion over the Improvement Standard persists,' wrote U.S. District Court Chief Judge Christina Reiss in Vermont in a decision released by the court Thursday. Advocates for seniors say coverage is often mistakenly denied simply because the beneficiary reaches “a plateau” and is no longer making progress.
Tuesday, May 17, 2016
CMS Publishes Final Rule for MSP Conditional Payments Via Web Portal
Friday, November 29, 2013
Changes to the Medicare Physician Fee Schedule for Calendar Year 2014
On November 27, 2013, the Centers for Medicare & Medicaid Services (CMS) finalized updates to payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2014. In recognizing the importance of care that occurs outside of a face-to-face visit, CMS finalized policies that will allow us to make a separate payment to physicians for managing select Medicare patients’ care needs beginning in calendar year (CY) 2015. The rule also finalizes changes to several of the quality reporting initiatives that are associated with PFS payments – the Physician Quality Reporting System (PQRS), as well as changes to the Physician Compare tool on the Medicare.gov website. Furthermore, the rule continues the phased-in implementation of the physician value-based payment modifier (Value Modifier), created by the Affordable Care Act, that will affect payments to certain physician groups based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program. Finally, the rule addresses changes to a handful of other programs which are listed in the Table of Contents within the rule.
This fact sheet discusses the changes to payment policies and payment rates for services furnished under the PFS. A separate fact sheet, also issued today, discusses the changes to the quality reporting programs, the Medicare EHR Incentive program, and the policies adopted for implementing the Value Modifier.
BACKGROUND
Since 1992, Medicare has paid for the services of physicians, non-physician practitioners (NPPs), and certain other suppliers under the PFS, a system that pays for covered physicians’ services furnished to a person with Medicare Part B. Under the PFS, relative values are assigned to each of more than 7,000 services to reflect the amount of work, the direct and indirect (overhead) practice expenses, and the malpractice expenses typically involved in furnishing that service. Each of these three relative value components is multiplied by a geographic practice cost index to adjust the payment for variations in the costs of furnishing services in different localities. The resulting relative value units (RVUs) are summed for each service and then are multiplied by a fixed-dollar conversion factor to establish the payment amount for each service. The higher the number of RVUs assigned to a service, the higher the payment.
Sustainable Growth Rate (SGR) and MPFS conversion factor for CY 2014: Under current law, physicians and non-physician practitioners (NPP) will face steep across-the-board reductions in payment rates, based on a formula—the Sustainable Growth Rate (SGR) methodology—which was adopted in the Balanced Budget Act of 1997. Without a change in the law, the conversion factor will be reduced by 20.1 percent for services in 2014. The President’s budget calls for averting these cuts and finding a permanent solution to this problem. The CY 2014 conversion factor is $27.2006, which reflects a smaller reduction in the conversion factor than the 24.4 percent reduction that we projected in March 2013. The smaller reduction is due in part to a 4.72 percent adjustment to the conversion factor to offset the decrease in Medicare physician payments that would otherwise have occurred due to the CY 2014 rescaling of the RVUs so that the proportions of total payments for the work, PE, and malpractice RVUs match the proportions in the final revised Medicare Economic Index (MEI) for CY 2014. This issue is discussed further below. The overall 2014 reduction in physician fee schedule payments required under the SGR methodology is unchanged by this rescaling.
PROVISIONS INCLUDED IN THE CY 2014 PFS FINAL RULE
Primary Care and Chronic Care Management: As part of our ongoing efforts to appropriately value primary care services, Medicare will begin making a separate payment for chronic care management services beginning in 2015. In last year’s final rule, we established separate payment for transitional care management services for a beneficiary making the transition from a facility to the community setting. In this final rule, we further emphasize our support for advanced primary care through our establishment of policies to facilitate separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple (two or more), significant chronic conditions. This reinforces Department of Health and Human Services (HHS) efforts to support care management through payment reform and incentives and is consistent with HHS’ Strategic Framework on Multiple Chronic Conditions. Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals; and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods.
The rule indicates that CMS intends to establish practice standards necessary to support payment for furnishing care management services through future notice-and-comment rulemaking.
Telehealth Services: We are modifying our regulations describing the geographic criteria for eligible telehealth originating sites to include health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy. We believe this change will more appropriately allow sites located within HPSAs in MSAs that have rural characteristics to qualify as originating sites and improve access to telehealth services in shortage areas. We are also establishing a policy to determine geographic eligibility for an originating site on an annual basis, consistent with other telehealth payment policies. This change will avoid mid-year changes to geographic designations (sometimes without advance notice to Medicare beneficiaries and providers) that could result in unexpected disruptions to established telehealth originating sites and avoid the need to make mid-year Medicare telehealth payment policy changes. In addition, we are updating the list of eligible Medicare telehealth services to include transitional care management services.
Revisions To The Practice Expense Geographic Adjustment: As required by the Medicare law, CMS adjusts payments under the PFS to reflect the local cost of operating a medical practice as compared to the national average. CMS calculates separate geographic practice cost indices (GPCIs) to adjust the work, practice expenses (PE), and malpractice cost components of each payment. The law requires that we review the GPCIs every three years and adjust them as appropriate with a two-year phase-in of the new GPCIs. We are finalizing new GPCIs using updated data. The updated GPCIs will be phased in over CY 2014 and CY 2015. Additionally, we will apply the statutorily mandated 1.5 work GPCI floor in Alaska and the 1.0 PE GPCI floor for frontier states (Montana, Nevada, North Dakota, South Dakota, and Wyoming), which have no expiration date. There is separate statutory 1.0 work GPCI floor that is scheduled to expire under current law on December 31, 2013. Therefore, the finalized GPCIs reflect the expiration of the 1.0 work GPCI floor.
Medicare Economic Index: CMS is finalizing proposed revisions to the calculation of the MEI, which is the price index used to update physician payments for inflation. The changes are in response to recommendations by a Technical Advisory Panel that met during CY 2012. Application of the MEI along with the SGR determines the conversion factor that is used to determine payments made each year under the PFS. The final rule includes changes in the PFS RVU and GPCI weights assigned to the work and practice expense categories so that the weights used in the PFS payment calculation will continue to mirror those in the MEI. As a result, some payment is being redistributed to work from practice expense. In addition, we are updating the GPCI cost share weights consistent with the revised 2006-based MEI cost share weights.
Misvalued Codes: Consistent with amendments made by the Affordable Care Act, CMS has been engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes, and make adjustments where appropriate. We are continuing to make strides as the values for around 200 codes were finalized and approximately 200 additional codes had their work relative value units changed on an interim basis for 2014. Included in these are services for hip and knee replacements, mental health services and GI endoscopy services. These rates are open for public comment until January 27, 2014.
CMS is not finalizing its proposal to adjust relative values under the PFS to effectively cap the physician practice expense payment for procedures furnished in a non-facility setting at the total payment rate for the service when furnished in an ambulatory surgical center or hospital outpatient setting. Instead, CMS will take additional time to consider issues raised by the public commenters and plans to address this issue in future rulemaking. In addition, for CY 2014, we are finalizing 18 codes that we identified and proposed as potentially misvalued services in consultation with Contractor Medical Directors.
Revisions to the Clinical Laboratory Fee Schedule (CLFS): Under current law, payments on the CLFS remain static and are not revised once a test code has been added to the CLFS and its payment rate has been established. At this point, the CLFS is approximately 30 years old with payment rates that are outdated and potentially excessive. This rule indicates that CMS intends to explore an existing statutory provision that allows updates to the CLFS based on changes in technology. As a result, for the first time, CMS will conduct regular reviews and updates to the payments on the CLFS in order to ensure greater payment accuracy.
Application of Therapy Caps to Critical Access Hospitals: The law applies annual limitations or “therapy caps” on per beneficiary incurred expenses for outpatient therapy services —one for physical therapy and speech-language pathology services combined and another for occupational therapy services. Before the American Taxpayers Relief Act of 2012 directed us to count CAH services towards the caps, the caps were not applied to therapy services furnished in Critical Access Hospitals (CAH). We are finalizing our proposal to apply the therapy caps and related policies to outpatient therapy services furnished by a CAH beginning on January 1, 2014 in order to properly apply the law that established the therapy caps.
Compliance with State Law for Incident To Services: We are requiring as a condition of Medicare payment that “incident to” services be furnished in compliance with applicable state law. This policy strengthens program integrity by allowing Medicare to deny or recoup payments when services are furnished not in compliance with state law. We also eliminated redundant regulations for each type of practitioner by consolidating the “incident to” requirements for all practitioners that are permitted to bill Medicare directly for their services, reducing the regulatory burden and making it less difficult for practitioners to determine what is required in order to bill Medicare for “incident to” services.
The final rule will appear in the December 10, 2013, Federal Register.
For more information, see: www.federalregister.gov/inspection.aspx#special
Wednesday, August 5, 2015
CMS to Speed-Up MSP Collection Practices
Tuesday, February 26, 2008
Medicare Finalizes New Rules To Collect Conditional Payments
CMS has designated third party administrators (TPAs) and self-insured plans as "primary payers."
The rule continues to provide that, "...As is the case with group health plan and large group health plan insurance, Medicare may not make payment if payment with respect to the same item or service has been made or can reasonably be expected to be made under workers' compensation..."
The final rule removes the requirement that the reimbursement will be made "promptly" and now substitutes that the primary payer is "...obligated to reimburse CMS if and when it is demonstrated that the primary payer has or had primary payment responsibility. This responsibility may be demonstrated by a judgment, a payment conditioned upon the recipient's compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items and services included in a claim against the primary payer, or by other means, including but not limited to a settlement, award, or contractual obligation. This means that a primary payer may not extinguish its obligations under the MSP provisions by paying the wrong party--for example, by paying the Medicare beneficiary or the provider when it should have reimbursed the Medicare program. Primary payers are expected to reimburse CMS when it is demonstrated that they have or had payment responsibility."
This rule supplements the recent legislation requiring the timely disclosure of information which was contained in the Medicare Medicaid and SCHIP Extension Act of 2007 and again reflects the Administration concern that cost shifting should not be transferred from workers' compensation onto CMS. The insurance industry continues to press for legislation that will would shift the burden from workers' compensation onto Medicare and require the US taxpayers to continue to supplement contested workers' compensation claims. CMS recently announced improper payments in 3 states amounted to $371.5 Million dollars alone. Previously this legislation was introduced and efforts to enact it failed.
Friday, November 19, 2010
US Seeks to Amend Complaint in Reimbursement Action to Define SOL
The Motion pleads, "Although the United States contends that it has set forth sufficient facts alleging its cause of action, the amendments set forth with more specificity (1) the Defendants’ payment of and receipt of annual payments made and received through 2013 as a result of the Abernathy Settlement Agreement, (2) their liability under the MSP Statute stemming from the annual payments, (3) additional information concerning the identified Medicare beneficiaries among the Abernathy Plaintiffs, (4) changes to certain allegations based on facts included in Court filings, and (5) the removal of The Cody Law Firm as a defendant."
Related articles
- Court Grants Motion to Reconsider Statute of Limitations in CMS Case (workers-compensation.blogspot.com)
- CMS Has 6 Year Statute of Limitations-Court Dismisses MSP Recovery Claim (workers-compensation.blogspot.com)
- USPS May Declare Bankruptcy Citing High Workers Compensation Costs (workers-compensation.blogspot.com)
Monday, November 9, 2015
CMS Has a New Play Book for Conditional Payments - The Time Factor
"...Upcoming Updates to the Medicare Secondary Payer Recovery Portal (MSPRP) Modification for Inclusion of Final Conditional Payment (CP) Process Functionality"
"As part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final CP process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.
"When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP.
- The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
- Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.
Related articles
- Court of Compensation Does Not Have Jurisdiction for Restitution (workers-compensation.blogspot.com)
- High Compensation Medical Costs Raises Concern in New Hampshire (workers-compensation.blogspot.com)
- Settling a Workers' Compensation Claim - Future Medicals and Medicare (workers-compensation.blogspot.com)
- The Affordable Care Act and Workers' Compensation: The Known Unknowns (workers-compensation.blogspot.com)
- CMS Posts Sample Notice To Beneficiaries Regarding Appeal Rights (workers-compensation.blogspot.com)
- CMS: "The Smarter Act" Introduced in the US Senate (workers-compensation.blogspot.com)
Wednesday, April 11, 2012
GAO Releases Report on Medicare Secondary Recovery Procedures
Identified Issues:
- Contractor performance. Challenges related to the timeliness of the MSPRC and WCRC were identified, including significant increases in the time required to complete important tasks. CMS reported taking steps to address the challenges with each of these contractors’ performance.
- Demand and recovery issues. Challenges were identified related to the timing of demand amounts, the cost-effectiveness of recovery efforts, and the amounts of Medicare demands from liability settlements. CMS reported taking steps to address some, but not all, of these challenges.
- Mandatory reporting. Key challenges were identified with certain aspects of mandatory reporting: determining whether individuals are Medicare beneficiaries, supplying diagnostic codes related to individuals’ injuries, and reporting all liability settlement amounts. CMS reported taking steps to address some, but not all, of these challenges.
- CMS guidance and communication. Key challenges were identified related to CMS guidance and communication about the MSP process, guidance on Medicare set-aside arrangements, and beneficiary rights and responsibilities. CMS has taken few steps to address these challenges.
"To improve the MSP program, GAO is making recommendations to improve the cost-effectiveness of recovery, decrease the reporting burden for NGHPs, and improve communications with NGHP stakeholders. CMS agreed with these recommendations."
Related articles
- Workers Compensation: A Cash Cow For Medical Providers (workers-compensation.blogspot.com)
- EPA Approves New Jersey's List of Polluted Water Bodies; Sewage Pollution Continues to be a Major Problem in New Jersey (workers-compensation.blogspot.com)
- Trending: Opting-Out of Workers' Compensation (workers-compensation.blogspot.com)
- Nursing Home Abuse: Drugging of Patients (workers-compensation.blogspot.com)
Monday, April 14, 2014
CMS Posts WCMSA Self-Administration Guidance
- New Self-Administration Toolkit for WCMSAs
- Account Expenditure for Lump Sum Account (Attestation Letter)
- Account Expenditure for Structured Annuity (Attestation Letter)
- Transaction Record Sample
- WCMSA Reference Guide
Monday, September 10, 2018
CMS has scheduled another webinar for Wed., Sept 19, 2018
Sunday, February 8, 2009
CMS May Participate in Conferences to Discuss Mandatory Reporting
PL110-173sec111-comments@cms.hhs.gov
The requests must include the following information:
-Conference Name/Title.
-Contact Person for the CMS Participation Request: Name/address/telephone/email.
-Sponsoring Organization: Name/address/telephone/email.
-Date(s) and Time(s) of Conference.
-Location of Conference: City/State.
-Approximate Number of Conference Attendees.
-Conference Topics: Please attach a draft agenda for the conference if available.
-Target Audience for the conference: Please be as specific as possible (for example, plaintiff attorneys, defense attorneys, insurers, third party administrators, risk managers, etc.).
-Scope of CMS participation requested: CMS needs to know whether audience interest is expected to be directed at Group Health Plan (GHP) related reporting issues as well as Liability -Insurance (including Self-Insurance), No-Fault Insurance, and Workers’ Compensation reporting issues or is expected to be more focused on some subset such as Workers’ Compensation reporting issues.
-Is the event open to the public?
CMS plans to respond within two weeks of the submitted request.
Thursday, October 27, 2016
CMS Town Hall Conference - Coordination of Benefits & Recovery for Liability Insurance (including Self-Insurance), NoFault Insurance and Workers’ Compensation
Coordination of Benefits & Recovery for Liability Insurance (including Self-Insurance), NoFault Insurance and Workers’ Compensation
On November 17, 2016, CMS will host a teleconference to connect with stakeholders and provide status updates. CMS expects to discuss the following topics:
- Ongoing Responsibility for Medicals (ORM) recovery,
- Final Conditional Payment (CP) process reminders,
- Medicare Secondary Payer Recovery Portal (MSPRP) improvements.
Monday, April 30, 2018
NJ Mandates Reporting of Medicare Conditional Payments
Monday, June 20, 2011
CMS Recovery Contractor Publishes New Rights and Responsibilities Letter
CMS employs outside contractors to collect conditional payments that Medicare has paid and for which it is only secondarily responsible
"The Medicare Secondary Payer Recovery Contractor (MSPRC) protects the Medicare trust fund by recovering payments Medicare made when another entity had primary payment responsibility. The MSPRC accomplishes these goals under the authority of the Medicare Secondary Payer (MSP) Act. The MSPRC identifies and recovers Medicare payments that should have been paid by another entity as the primary payer either under a Group Health Plan (GHP) or as part of a Non-Group Health Plan (NGHP) claim which includes, but is not limited to Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers' Compensation. The MSPRC does not pursue supplier, physician, or other provider recovery'."
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.
Related articles
- Medicare to Partially Resume Workmens Comp Collection Letters (workers-compensation.blogspot.com)
- Halted: Medicare Secondary Payer Recovery Contractor Demand Letters (workers-compensation.blogspot.com)
- Should CMS be A Joint Payee in a Workers Comp Settlement? (workers-compensation.blogspot.com)
- Federal Court Enjoins CMS From MSP Recovery Procedures (workers-compensation.blogspot.com)
- Court Permits Deduction of Procurement Costs From Medicare Set-Aside in Liability Claim (workers-compensation.blogspot.com)
- CMS Announces Review is Only a Recommended Process for Set-Aside Agreements (workers-compensation.blogspot.com)