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Medicare Subrogation a.k.a. - Medicare Secondary Payer Liability and No-Fault Public Information Available at No Charge Sally Stalcup Region 6 MSP Regional.

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Presentation on theme: "Medicare Subrogation a.k.a. - Medicare Secondary Payer Liability and No-Fault Public Information Available at No Charge Sally Stalcup Region 6 MSP Regional."— Presentation transcript:

1 Medicare Subrogation a.k.a. - Medicare Secondary Payer Liability and No-Fault Public Information Available at No Charge Sally Stalcup Region 6 MSP Regional Coordinator

2 The History of MSP 4 7/1/66MedicareWorker’s Comp, VA, Black Lung, Federal Programs 4 12/5/80OBRAAuto-Medical, No-Fault, Liability 4 10/1/81OBRA-81ESRD 4 10/1/83TEFRAWorking Aged 4 1/1/85DEFRAWorking Aged 4 5/1/86COBRAWorking Aged 4 1/1/87OBRA-86Disability BBAVarious 4 12/8/03MMATechnical/Clarifying Amendments

3 Legal Authority for Recovery 4 Section 1862(b)-(2)(A)(ii) of the Social Security Act 4 Medicare Prescription Drug and Modernization Act of CFR 411 –42 CFR –42 CFR –42 CFR –42 CFR

4 MSP Resources 4 Section 1862 (42 U.S. C. 1395y) of the Social Security Act (the "Act"). 4 Section 1870 of the Act, Overpayment on Behalf of Individuals and Settlement of Claims for Benefits on Behalf of Deceased Individual 4 REGULATIONS: 4 42 CFR Part 405, 's 4 42 CFR Part 411, Exclusions from Medicare and Limitations on Medicare Payment, Subparts B-H 4 Subpart B- Insurance Coverage that Limits Medicare payment: General Provisions 4 Subpart C - Limitations on Medicare Payment for Services Covered Under 4 Workers' Compensation 4 Subpart D - Limitations on Medicare Payment for Services Covered Under 4 Liability or No-Fault Insurance 4 Subpart E - Limitations on Payment for Services Covered Under Group Health 4 Plans: General Provisions 4 Subpart F - Special Rules: Individuals Eligible or Entitled on the Basis of ESRD 4 Who are also covered under group health plans 4 Subpart G - Special Rules: Aged Beneficiaries and Spouses who are also covered 4 Under Group Health Plans 4 Subpart H: Special Rules: Disabled Beneficiaries who are also covered under 4 Large Group Health Plans 4 Subpart C of 42 CFR Part 405, for regulations to Section 1870 Wavier of Recovery 4 42 CFR Part Amount of Medicare recovery when a third party payment is made as a result of a result of a settlement, judgment or award. 4 PUBLICATIONS: 4 Medicare and Other Health Benefits: Your Guide as to Who Pays First 4 Medicare Coverage of Kidney Dialysis and Kidney Transplant Services 4 These publications can be found on the internet at

5 The Basics: What we do Medicare pursues reimbursement where payment has been or can reasonably be expected to be made promptly under any of the following: 4 Workers’ Compensation 4 Liability Insurance Includes, but not limited to: automobile liability, uninsured, underinsured; PIP/Med-pay; homeowners; wrongful death; malpractice; product liability including self insured plans 42 CFR No-Fault Insurance 4 *FTCA Federal Tort Claims Act See 42 C.F.R.§411 et al.

6 The Basics: Who We Are 4 CMSCenters for Medicare & Medicaid Services 4 COBC Coordination of Benefits Contractor 4 MSPRCMedicare Secondary Payer Recovery Contractor - Chickasaw Nation Industries, Inc. Administration Services, LLC (CNI)

7 MSPRC Effective October 2, 2006, The Centers for Medicare & Medicaid Services (CMS) awarded a contract for one national Medicare Secondary Payer Recovery Contractor (MSPRC) to: Chickasaw Nation Industries, Inc. – Administration Services, LLC (CNI).

8 MSPRC Continued The MSPRC has responsibility for all MSP recovery cases with three exceptions: (1) MSP recovery demand letters issued by the claims processing contractors to providers, physician, and other suppliers, ( 2) demand letters issued by the MSP Recovery Audit Contractors (RACs) implemented as a demonstration under the Medicare Modernization Act of 2003 and. The RACs will continue to have responsibility for certain MSP GHP based recovery demands for the States of California, Florida, and New York and (3) TrailBlazer Health Enterprise, LLC, (along with Empire – Syracuse NY or Harrisburg PA, First Coast Service Options – Jacksonville FL, Mutual of Omaha – Omaha NE, and Palmetto – Augusta GA or Columbia SC or Columbus OH) retained any case for which they had already issued a formal demand for payment.

9 Federal Tort Claim Act Cases 4 All Federal Tort Claim Act (FTCA) cases are handled by Betty Noble in CMS Central Office. Please contact: Betty Noble CMS 7500Security Blvd, Mail Stop C Baltimore, Maryland (410)

10 Medicare Secondary Payer The Recovery Process

11 Attorney’s Obligation Regarding Medicare 4 To notify Medicare immediately when you/your firm is retained to represent a client who is entitled to Medicare benefits. (42 U.C.S Section 1395y(b)) 4 Once you/your firm is retained, it is in your capacity as an officer of the court and under CMS regulations to see that Medicare’s interests are protected. 4 42CFR part (g)

12 Global or Multi-Jurisdictional Cases 4 If your case involves a product liability case with a global settlement please contact Sally Stalcup before you contact the COBC. 4 If you are participating in multi- jurisdictional, or multi-client global product liability case, please contact Sally Stalcup before contacting the COBC.

13 What To Provide On Your Letterhead – Or By Phone 4 Medicare beneficiary full name, address and HIC (standard is 9 numbers with a letter suffix) 4 Medicare beneficiary date of birth 4 Type of Incident (liability, no-fault, W/C, etc) 4 Date of Incident/ingestion/exposure 4 Your full name, address, telephone number 4 Opposing counsel name, address, number 4 Insurance company name, address, number, agent name and policy/claim number 4 Listing of all claimed injuries/illnesses

14 Medicare’s Recovery Process: Case Assigned to MSPRC 4 You’ve notified COBC of a potential MSP case 4 Medicare creates a file and verifies the Privacy Release 4 Medicare identifies related claims and sends notice 4 Beneficiary and attorney review claims 4 Settlement data added 4 Medicare calculates procurement reduction (42 CFR ) & issues demand letter 4 Payment to Medicare within 60 days

15 Payment Summary Form

16 Medicare Recovery Which Claims Count? Two-Prong Test #1 Is the claim “related to” the incident? -- If yes, then Medicare recovers -- If no, ask question #2 #2 Was claim used to procure settlement? -- If yes, then Medicare recovers -- If no, then Medicare does not recover

17 Why does it take so long to tell me the amount due? 4 Before a settlement is reached between the beneficiary and the liable party or a judgment is rendered by a court, there is no overpayment. 4 Response to contractor after reviewing identified conditional payments 4 Medicare must be provided with a copy of a settlement agreement from the third party showing the total amount of the settlement, signed and dated by the Medicare beneficiary or their legal representative, and your closing settlement reflecting the actual amount of attorney’s fees and procurement costs (case expenses). 4 ReMAS implementation 4 Conversion to MSPRC – new and prior backlogs

18 ReMAS 4 Recovery Management and Accounting System (ReMAS) identifies mistaken Medicare primary payments. It replaced and merged several contractor & CMS systems into one centralized database. While ReMAS is researching the centralized database to identify those conditional payments, the case is completely outside the control of the MSPRC or the CMS Regional Office.

19 ReMAS 4 Once MSPRC receives an alert that ReMAS has pulled all related claims, they will average 45 days to issue an interim notification of identified payments to the Medicare beneficiary and, if authorized by a valid privacy release, their attorney. Events such as the installation of ReMAS, HIGLAS (the new financial management and accounting system), and transition to MSPRC, have resulted in delays.

20 Three Issues Can be Appealed 4 The existence of the overpayment 4 The amount of the overpayment 4 A less than fully favorable determination of an 1870(c) waiver request **An appeal may only be requested by an entity deemed “party to an appeal”

21 What If I Want to Negotiate With Medicare? 4 Waiver Option #1: §1870(c) Waiver Contractor-based waiver decision based upon two key considerations: 1.Financial Hardship 2.Equity & Good Conscience 4 Compromises Federal Claims Collection Act – handled by CMS Regional Offices 4 Waiver Option #2: §1862(b) Waiver Only CMS can consider §1862(b) waivers. Must be in best interest of the Medicare Program and is virtually never used.

22 Waivers Limited Availability -- The beneficiary -- A surviving spouse or dependent who is entitled to either : a) Social Security Disability Insurance Payments (Title II) or b) Medicare

23 Compromises 4 The Federal Claims Collections Act provides CMS with authority to compromise claims – pre or post settlement. 4 Contractors have no compromise authority. 4 CMS must refer every favorable compromise determination of a debt of $100, or more to the Department of Justice (DOJ) for final determination.

24 Compromise - What to Send 4 Medicare Beneficiary Full Name, Medicare number, date of incident/ingestion/exposure 4 Settlement specifics - a copy of the settlement agreement from the third party showing the total amount of the settlement, signed and dated by your client, and your closing settlement reflecting the actual amount of attorney’s fees and case expenses. 4 Valid privacy release or a copy of your representation contract signed by the Medicare beneficiary 4 Incident/case related facts which you believe support a favorable decision 4 Medicare beneficiary financial information such as monthly income and expenses, assets & debts, documentation of loss of income due to what was claimed and/or released in the settlement, judgment, or award, expenses for widened doorways, ramps, absence of Medigap insurance, and/or other medical out-of-pocket expenses, etc.

25 Confidentiality 4 Confidentiality clauses, while not illegal, are contrary to public policy; therefore, no agreement may contain such a clause except when DOJ advises that it would be recommended in the course of litigation.

26 Future Medicals Liability & Workers’ Compensation 4 Medicare must be protected any time a Medicare beneficiary recovers for future medicals. 4 There is no formal CMS review process in the liability arena as there is for Worker’ Compensation. However, CMS does expect the funds to be exhausted on Medicare covered services before Medicare is ever billed.

27 Medicare Set-Asides Section 1862(b)(2)(A)(ii) of the Social Security Act precludes Medicare payment for services to the extent that payment has been made or can reasonably be expected to be made promptly under liability insurance. This also governs Workers’ Compensation. 42 CFR defines liability insurance. Anytime a settlement, judgment or award provides funds for future medical services, it can reasonably be expected that those funds are available to pay for Medicare covered future services related to what was claimed and/or released in the settlement, judgment, or award. Thus, Medicare should not be billed for future services until those funds are exhausted by payments to providers for services that would otherwise be covered by Medicare.

28 Medicare Set-Asides The fact that a settlement/judgment/award does not specify payment for future medical services does not mean that they are not funded. 4 The fact that the agreement designates the entire amount for pain and suffering does not mean that future medicals are not funded.

29 Medicare Set-Asides Cont. 4 While it is Medicare’s position that counsel should certainly know whether or not their recovery provides for future medicals, simply recovers policy limits, etc, we are frequently asked how one would ‘know’. Consider the following examples as a guide for determining whether or not settlement funds must be used to protect Medicare’s interest on any otherwise Medicare covered, case related, future medical services. Does the case involve a catastrophic injury or illness? Is there a Life Care Plan or similar document? Does the case involve any aspect of Workers’ Compensation? This list is by no means all inclusive.

30 Medicare Set-Asides We use the phrase “case related” because we consider more than just services related to the actual injury/illness which is the basis of the case. Because the law precludes Medicare payment for services to the extent that payment has been made or can reasonably be expected to be made promptly under liability insurance, Medicare’s right of recovery, and the prohibition from billing Medicare for future services, extends to all those services related to what was claimed and/or released in the settlement, judgment, or award. Medicare’s payment for those same past services is recoverable and payment for those future services is precluded by Section 1862(b)(2)(A)(ii) of the Social Security Act.

31 Otherwise Medicare Covered 4 “Otherwise covered” means that the funds must be used to pay for only those services Medicare would cover so there is a savings to the Medicare trust fund. For example, Medicare does not pay for bathroom grab bars, handicapped vans, garage door openers or spas so use of the funds for those items is inappropriate.

32 Medicare Set-Asides In Liability Cases 4 At this time, the Centers for Medicare & Medicaid Services (CMS) is not soliciting cases solely because of the language provided in a general release. CMS does not review or sign off on counsel’s determination of the amount to be held to protect the Trust Fund in most cases. We do however urge counsel to consider this issue when settling a case and recommend that their determination as to whether or not their case provided recovery funds for future medicals be documented in their records. Should they determine that future services are funded, those dollars must be used to pay for future otherwise Medicare covered case related services. 4 There is no formal CMS review process in the liability arena as there is for Worker’ Compensation. 4 On rare occasions, when the recovery is large enough, or other unusual facts exist within the case, this CMS Regional Office will review the settlement and help make a determination on the amount to be available for future services.

33 Interest 4 Remember, interest accrues on amount owed Medicare after 60 days of settlement. 45 CFR §30.13, 30.14(a) 42 CFR §411.24(h) Consider the impact of interest on decision to pursue a waiver or compromise.

34 I Didn’t Know My Client Had Medicare Suspect Medicare’s Involvement 4 Any time your client is Any time your client is disabled

35 Who Else? 4 Medicare Managed Care Plans 4 Part D Prescription Drug Coverage If the Medicare beneficiary is enrolled in either you should contact that plan apart from your notice to COBC to determine their recovery interest.

36 Coordination of Benefits Contractor Medicare - COB MSP Claims Investigation Project P.O. Box 5041 New York, NY voice (800) fax (646) or 6762

37 MSPRC 4 MSPRC Auto, No-Fault & Liability Detroit, MI P. O. Box 33828(866) MSP-RC20 (866) MSPRC Workers’ Compensation P. O. Box Detroit, MI MSPRC GHP P. O. Box Detroit, MI

38 For More Information:

39 CMS Contact Information 4 Liability/No-Fault/Workers’ Compensation Sally Stalcup (214) Workers’ Compensation lead/Older Worker Lindsey Kittrell (214)

40 ??? Future Medicals ? TrailBlazer MSPRC COBC


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