Presentation on theme: "Medicare Subrogation a.k.a. - Medicare Secondary Payer Liability and No-Fault Public Information Available at No Charge Sally Stalcup Region."— Presentation transcript:
1 Medicare Subrogationa.k.a. - Medicare Secondary Payer Liability and No-FaultPublic Information Available at No ChargeSally StalcupRegion 6MSP Regional Coordinator
2 The History of MSP7/1/66 Medicare Worker’s Comp, VA, Black Lung, Federal Programs12/5/80 OBRA Auto-Medical, No-Fault, Liability10/1/81 OBRA-81 ESRD10/1/83 TEFRA Working Aged1/1/85 DEFRA Working Aged5/1/86 COBRA Working Aged1/1/87 OBRA-86 Disability1997 BBA Various12/8/03 MMA Technical/Clarifying Amendments
3 Legal Authority for Recovery Section 1862(b)-(2)(A)(ii) of the Social Security ActMedicare Prescription Drug and Modernization Act of 200342 CFR 41142 CFR42 CFR42 CFR42 CFR
4 MSP ResourcesSection 1862 (42 U.S. C. 1395y) of the Social Security Act (the "Act").Section 1870 of the Act, Overpayment on Behalf of Individuals and Settlement of Claims for Benefits on Behalf of Deceased IndividualREGULATIONS:42 CFR Part 405, 's42 CFR Part 411, Exclusions from Medicare and Limitations on Medicare Payment, Subparts B-HSubpart B- Insurance Coverage that Limits Medicare payment: General ProvisionsSubpart C - Limitations on Medicare Payment for Services Covered UnderWorkers' CompensationSubpart D - Limitations on Medicare Payment for Services Covered UnderLiability or No-Fault InsuranceSubpart E - Limitations on Payment for Services Covered Under Group HealthPlans: General ProvisionsSubpart F - Special Rules: Individuals Eligible or Entitled on the Basis of ESRDWho are also covered under group health plansSubpart G - Special Rules: Aged Beneficiaries and Spouses who are also coveredUnder Group Health PlansSubpart H: Special Rules: Disabled Beneficiaries who are also covered underLarge Group Health PlansSubpart C of 42 CFR Part 405, for regulations to Section 1870 Wavier of Recovery42 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.PUBLICATIONS:Medicare and Other Health Benefits: Your Guide as to Who Pays FirstMedicare Coverage of Kidney Dialysis and Kidney Transplant ServicesThese publications can be found on the internet at
5 The Basics: What we doMedicare pursues reimbursement where payment has been or can reasonably be expected to be made promptly under any of the following:Workers’ CompensationLiability InsuranceIncludes, but not limited to: automobile liability, uninsured, underinsured; PIP/Med-pay; homeowners; wrongful death; malpractice; product liability including self insured plans CFRNo-Fault Insurance*FTCAFederal Tort Claims ActSee 42 C.F.R.§411 et al.Liability Insurance = insurance (including a self-insured plan) that provides payment based on legal liability for injury or illness or damage to property. This includes, but is not limited to auto liability insurance, uninsured motorist insurance, underinsured motorist insurance, homeowner's liability insurance, malpractice insurance, product liability insurance, and general casualty insurance.No Fault Insurance = insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile. This includes, but is not limited to, automobile, homeowners, and commercial plans. It is sometimes called "medical payments coverage," "personal injury projection," or "medical expense coverage."
6 The Basics: Who We Are CMS Centers for Medicare & Medicaid Services COBC Coordination of Benefits ContractorMSPRC Medicare Secondary Payer Recovery Contractor Chickasaw Nation Industries, Inc.Administration Services, LLC (CNI)
7 MSPRCEffective 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 ContinuedThe MSPRC has responsibility for all MSP recovery cases with three exceptions: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 All Federal Tort Claim Act (FTCA) cases are handled by Betty Noble in CMS Central Office. Please contact:Betty NobleCMS7500Security Blvd, Mail Stop CBaltimore, Maryland(410)
11 Attorney’s Obligation Regarding Medicare 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))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.42CFR part411.24(g)
12 Global or Multi-Jurisdictional Cases If your case involves a product liability case with a global settlement please contact Sally Stalcup before you contact the COBC.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 Medicare beneficiary full name, address and HIC (standard is 9 numbers with a letter suffix)Medicare beneficiary date of birthType of Incident (liability, no-fault, W/C, etc)Date of Incident/ingestion/exposureYour full name, address, telephone numberOpposing counsel name, address, numberInsurance company name, address, number, agent name and policy/claim numberListing of all claimed injuries/illnesses
14 Medicare’s Recovery Process: Case Assigned to MSPRC You’ve notified COBC of a potential MSP caseMedicare creates a file and verifies the Privacy ReleaseMedicare identifies related claims and sends noticeBeneficiary and attorney review claimsSettlement data addedMedicare calculates procurement reduction (42 CFR ) & issues demand letterPayment to Medicare within 60 days
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 no, then Medicare does not recoverImportant to Note:Medicare has an INTEREST not a lien.-- in ZINMAN V SHALALA (US Dist Ct, ND Calif; 835 F.Supp 1163), the Court instructed the Secretary of HHS to cease using the term lien.-- Medicare's right to recover is superior to a lien.-- Medicare is subrogated to the beneficiary's right to collect insurance proceeds-- Medicare is not required to, and does not, file liens to recover its interest.RELATED TO. You give us injuries. If the claim diagnosis codes match those injuries, we recover.To EXCLUDE, send written documentation from DR noting that the treatment was for a preexisting condition that was not exacerbated by the accident.USED TO PROCURE SETTLEMENT. If you included "unrelated" claims in your initial pleadings, then Medicare recovers.To EXCLUDE (1) send us written documentation from the insurer advising Medicare that their payment was not for the contested claims, or (2) return to us with your notarized statement a completed form indicating that you did not use the contested claims to procure settlement in the matter.PAIN & SUFFERING. xxx
17 Why does it take so long to tell me the amount due? Before a settlement is reached between the beneficiary and the liable party or a judgment is rendered by a court, there is no overpayment.Response to contractor after reviewing identified conditional paymentsMedicare 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).ReMAS implementationConversion to MSPRC – new and prior backlogs
18 ReMASRecovery 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 ReMASOnce 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 The existence of the overpaymentThe amount of the overpaymentA 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? Waiver Option #1: §1870(c) Waiver Contractor-based waiver decision based upon two key considerations:1. Financial Hardship2. Equity & Good ConscienceCompromisesFederal Claims Collection Act – handled by CMS Regional OfficesWaiver 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 dependentwho is entitled to either :a) Social Security Disability Insurance Payments (Title II)orb) Medicare
23 CompromisesThe Federal Claims Collections Act provides CMS with authority to compromise claims – pre or post settlement.Contractors have no compromise authority.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 Medicare Beneficiary Full Name, Medicare number, date of incident/ingestion/exposureSettlement 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.Valid privacy release or a copy of your representation contract signed by the Medicare beneficiaryIncident/case related facts which you believe support a favorable decisionMedicare 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 ConfidentialityConfidentiality 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 Medicare must be protected any time a Medicare beneficiary recovers for future medicals.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. 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. 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 “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 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.There is no formal CMS review process in the liability arena as there is for Worker’ Compensation. 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 InterestRemember, 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 InvolvementAny time your client is 65+Any time your client is disabled
35 Who Else? Medicare Managed Care Plans Part D Prescription Drug CoverageIf 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 - COBMSP Claims Investigation ProjectP.O. Box 5041New York, NYvoice (800)fax (646) or 6762
37 MSPRC MSPRC Auto, No-Fault & Liability Detroit, MI 48232-3828 P. O. Box (866) MSP-RC (866)MSPRC Workers’ CompensationP. O. Box 33831Detroit, MIMSPRC GHPP. O. Box 33829Detroit, MI